Assessing diagnostic certainty for scurvy and rickets in human skeletal remains

OBJECTIVES

Identifying scurvy and rickets has important implications for understanding adaptations and variability among past communities, and bioarchaeologists now regularly evaluate these conditions. Due to the increased number of studies, cases with less clear-cut lesions and variable preservation are now frequently reported. Despite an improved understanding of the biological mechanisms for disease expression, there is a lack of consensus on the language used to express diagnostic certainty, limiting comparability. This article aims to address these issues and provide recommendations on more consistent diagnostic terminology using widely accepted diagnostic methodology based on biological mechanisms.

MATERIALS AND METHODS

We review diagnostic terms used in bioarchaeology by considering published cases of rickets, scurvy and co-occurrence alongside M.B.B.'s past project notes. We also consider differences in the diagnosis of rickets and scurvy in living and archeological individuals.

RESULTS

We provide recommendations on a framework that can be used to show diagnostic certainty in cases of rickets, scurvy, and co-occurrence. Core lesions of rickets and scurvy are used alongside a limited lexicon of diagnostic terminology based on the Istanbul protocol.

DISCUSSION

It is not the number of lesions that determines whether an individual is assigned to a particular diagnosis category, but rather the range and expression of lesions present. Avoiding a "tick-list" approach to core lesions of these diseases will be critical to ensure that identifying rickets and scurvy continues to contribute to understanding adaptations and variability among past communities. The framework allows more consistency in diagnostic certainty, facilitating greater comparability in research.

What constitutes a high-quality, comprehensive medico-legal asylum affidavit in the United States immigration context? A multi-sectoral consensus-building modified Delphi

In the United States, clinicians are often called upon to provide their expertise to generate expert evidence in cases of individuals seeking asylum or other forms of international protection. Due to a lack of validated guidelines specific to the U.S. immigration context, clinical evaluations produced for immigration proceedings in the United States vary in their format, structure, and content, which can be confusing for practitioners and for adjudicators assessing the weight these evaluations should be afforded in asylum proceedings. We sought to review critical components of a medico-legal asylum evaluation from an interdisciplinary perspective of key stakeholders, by collecting and synthesizing expert opinions to reach consensus on what constitutes a high-quality, comprehensive medical or psychological affidavit for U.S. immigration cases. The consensus process incorporated a three-step modified Delphi method, which took place between September and December 2021 and consisted of two rounds of online questionnaires and a synchronous video conference meeting. The areas most experts agreed on included, by order of highest agreement (combining answers of "strongly agree" and "agree"): A narrative form or checklist is preferable to a predetermined template (95%); Primary care physicians should describe their qualifications to diagnose mental health conditions (81%); Use of citation is helpful, with caveats (77%); Clinicians should include an assessment of malingering (72%); Clinicians should include an executive summary/summary of conclusions at the top of the affidavit (72%); Clinicians should reference the Istanbul Protocol and explain its relevance (66%); It may be beneficial for clinicians to describe the anticipated process of healing (57%); Clinicians may include treatment recommendations (52%). Results of this and future consensus-building efforts and resulting guidance should be used to enhance overall quality of medico-legal reports and incorporated in training programs developed for clinicians, attorneys and adjudicators.

Tortures alleged by migrants in Italy: compatibility and other medicolegal challenges

Background

Illegal immigration to Europe is a well-known phenomenon whose numbers are being steadily increasing in recent years. Most of the immigrants in Italy come from war zones, and many of them submit an asylum application supported by the complaint to have been victims of persecutory acts in their home countries.

Material and methods

One hundred ninety-six medicolegal reports are analyzed considering the different country of origin, the type of the lesions claimed, tools used, evidenced effects, location of the perpetration of the physical abuses, and the possible motivation of the alleged torture.

Results

Greater than 80% of the assessed asylum seekers are over 18-year males coming from African countries. Fifty-eight percent of migrants were tortured or abused in countries of transit, 95% in Libya. Economic, familial, politic, and ethnic reasons prevail in some countries of origin, while tortures or abuses perpetrated in transit countries are mainly linked to forced labor and detention. In the 42.2% of cases, no physical evidence of tortures was detected. The Istanbul Protocol resulted to have been only partly applicable and about 40% of the medicolegal reports are “inconclusive” about the compatibility of physical evidence with the alleged tortures.

Conclusions

The medicolegal and forensic experts involved in torture and ill-treatment cases should seek specific education and training to lower the risks of underestimation and the rate of inconclusive reports. More extensive implementation of the Istanbul Protocol in daily practice should be pursued by the authorities in charge of asylum or protection releasement.

Beyond torture checklists: an exploratory study of the reliability and construct validity of the Torturing Environment Scale (TES)

Background

Torture methods have traditionally been quantified using checklists. However, checklists fail to capture accurately both the almost infinite range of available methods of torture and the victims’ subjective experience. The Torturing Environment Scale (TES) was designed as a multidimensional alternative that groups torture methods according to the specific human function under attack. This study aims to do an exploratory assessment of the internal consistency reliability and discriminatory validity of the TES as part of a construct validity assessment in a sample of Basque torture survivors.

Methods

We applied the TES to a sample of 201 torture survivors from the Istanbul Protocol Project in the Basque Country Study (IPP-BC) to profile torturing environments in detention. To estimate the internal consistency reliability of the scale, categorical omega values were obtained for each subscale of the TES. To assess its discriminatory validity, the “known groups” method was used comparing mean scorings by gender, state security forces involved in the detention, and decade (the 1980s to the present) when the events took place.

Results

Men reported more physical pain, while women reported more attacks on self-identity and sexual integrity. The TES also showed significant differences as regards the security forces involved in the detention: Civil Guard (a militarised police) used more manipulation of the environment, threats, fear, pain and extreme pain, as compared to national and regional corps. Finally, although patterns of torture remained mostly unchanged across decades, more recent detentions included more emphasis on psychological attacks: context manipulation, humiliation linked to sexual identity, and attacks to meaning and identity. For all subscales of the TES, categorical omega values ranged from 0.44 to 0.72.

Conclusion

The TES may be a useful tool in profiling torturing environments. Its sensitivity to key contextual variables supports the discriminatory validity of the scale. While some of the subscales showed an acceptable degree of internal consistency, others require further analysis to improve reliability. The scale provides unique insights into the profile of contemporary torture. It will allow for future quantitative research on the relationship between different torturing environments and the medical and psychological consequences thereof.

Attitudes and experiences of health professionals towards clinical evaluations of torture and ill-treatment

Torture and ill-treatment are crimes practiced systematically in many countries around the world. Little is known about the attitudes and experiences of health professionals who evaluate the victims of these crimes. This study was conducted to assess the attitudes and experiences of health professionals who conduct clinical evaluations of alleged torture and ill-treatment and identify common needs and challenges. Two surveys were administered to health professionals who attended a series of Istanbul Protocol (IP) trainings in various countries of Central Asia, Middle East/North Africa and Latin-America. The findings indicate that participants documented a significant number of torture and ill-treatment cases during a three-year period preceding the survey and that they were interested in conducting evaluations in accordance with the IP, but expressed concern about the impact of such evaluations on their workload and the effects of secondary trauma. Participants indicated support for a wide range of professional development and self-regulatory measures. The study also indicates the need for additional training and other measures to ensure effective documentation practices as 13% of participants failed to understand one of the most basic IP concepts - that the absence of physical and/or psychological evidence does not rule out the possibility that torture and/or ill-treatment occurred.

Evaluation of medical examination of forensic medicine specialists during / after detention within the scope of Istanbul Protocol

INTRODUCTION

The Istanbul Protocol is a document prepared by many scientists from different countries and accepted by the United Nations thematising the medical reporting of torture. Normally, forensic specialists are responsible for medical examinations of torture victims, but this study looks at forensic specialists who were themselves subject to torture and mistreatment. It aims to analyze and evaluate, especially with regard to the Istanbul Protocol, the medical examinations performed on them while they were in detention.

MATERIAL/METHOD

This study includes experts in forensic science who were detained during and after the state of emergency that was declared in 2016 in Turkey. Participants were asked questions regarding the examination steps specified in the Istanbul protocol. The Google Forms system (Google Inc., CA/USA) was used for the surveys, sent to the participants via text message.

RESULTS

Twenty-two forensic scientists who were detained during and after the state of emergency in Turkey participated in this study. 45.5% of the participants were not asked for identification before their medical examination in detention. 36.4% of the participants stated that police were present in the examination room. Only 13.6% of participants found the privacy conditions during the examination appropriate. 90.9% stated that the time allocated for the examination was insufficient. The medical examinations lasted from 10 s to 10 min. Most participants were examined in less than 5 min. When asked if they were abused, 22.7% stated that they were not tortured, and 77.3% stated that they were subjected to torture or mistreatment practices, such as beatings, inappropriate use of handcuffs, being forced to wait or being rushed unnecessarily, being abandoned in isolating or hostile environments. In addition, the questions required to assess the psychological indications of torture and maltreatment were never asked in 40.9% of the cases.

DISCUSSION AND CONCLUSION

Although torture is prohibited by international and humanitarian law, it has not completely disappeared. Medical personnel play an important role in torture assesment and prevention. The testimony of the forensic experts, who were fired and detained, revealed that the medical examinations during and after the State of Emergency in Turkey did not comply with the Istanbul Protocol and ethical rules. Medical examinations not carried out in accordance with the Istanbul Protocol lead to the denial of many rights and health problems. A worldwide awareness and sensitivity is needed to solve this problem.

Documentation of human rights abuses among Rohingya refugees from Myanmar

BACKGROUND

Decades of persecution culminated in a statewide campaign of organized, systematic, and violent eviction of the Rohingya people by the Myanmar government beginning in August 2017. These attacks included the burning of homes and farms, beatings, shootings, sexual violence, summary executions, burying the dead in mass graves, and other atrocities. The Myanmar government has denied any responsibility. To document evidence of reported atrocities and identify patterns, we interviewed survivors, documented physical injuries, and assessed for consistency in their reports.

METHODS

We use purposive and snowball sampling to identify survivors residing in refugee camps in Bangladesh. Interviews and examinations were conducted by trained investigators with the assistance of interpreters based on the Istanbul Protocol - the international standard to investigate and document instances of torture and other cruel, inhuman, and degrading treatment. The goal was to assess whether the clinical findings corroborate survivors' narratives and to identify emblematic patterns.

RESULTS

During four separate field visits between December 2017 and July 2018, we interviewed and where relevant, conducted physical examinations on a total of 114 refugees. The participants came from 36 villages in Northern Rakhine state; 36 (32%) were female, 26 (23%) were children. Testimonies described several patterns in the violence prior to their flight, including the organization of the attacks, the involvement of non-Rohingya civilians, the targeted and purposeful destruction of homes and eviction of Rohingya residents, and the denial of medical care. Physical findings included injuries from gunshots, blunt trauma, penetrating trauma such as slashings and mutilations, burns, and explosives and from sexual and gender-based violence.

CONCLUSIONS

While each survivor's experience was unique, similarities in the types and organization of attacks support allegations of a systematic, widespread, and premeditated campaign of forced displacement and violence. Physical findings were consistent with survivors' narratives of violence and brutality. These findings warrant accountability for the Myanmar military per the Rome Statute of the International Criminal Court (ICC), which has jurisdiction to try individuals for serious international crimes, including crimes against humanity and genocide. Legal accountability for these crimes should be pursued along with medical and psychological care and rehabilitation to address the ongoing effects of violence, discrimination, and displacement.

Cross-sectional study on awareness and knowledge of torture investigation and documentation among Greek doctors and senior medical students

Doctors in Greece face the possibility of encountering a person that has suffered torture, especially since the high rates of refugees' and migrants' inflows that took place over the last years. In order to assess the awareness and the knowledge of doctors and senior medical students in Greece regarding a manual on effective investigation and documentation of torture such as Istanbul Protocol (official United Nation document since 1999), a cross-sectional study was conducted using a structured anonymous questionnaire. The sample was doctors practicing in public hospitals in Greece, doctors volunteering at a non-governmental organization (NGO) and undergraduate medical students in their final year of studies in the Medical School of National and Kapodistrian University of Athens. The data were analyzed using IBM SPSS version 23, using descriptive statistics and statistical significance tests.In a total of 289 participants, the mean total score of Istanbul Protocol knowledge was 4.43 ± 1.104 (the maximum possible score was 10) and the mean total score of Istanbul Protocol awareness was 2.04 ± 1.521 (the maximum possible score was 10). The most important conclusion was that among doctors and senior medical students, there seem to be knowledge, awareness, and information deficit about Istanbul Protocol and several issues relating to torture. The overall research outcome highlights the need for the development of a relevant informative/educational program, in order to cover the corresponding existing needs of the population of doctors in Greece.