Fibrodysplasia Ossificans Progressiva: What Have We Achieved and Where Are We Now? Follow-up to the 2015 Lorentz Workshop

Fibrodysplasia ossificans progressiva (FOP) is an ultra-rare progressive genetic disease effecting one in a million individuals. During their life, patients with FOP progressively develop bone in the soft tissues resulting in increasing immobility and early death. A mutation in the ACVR1 gene was identified as the causative mutation of FOP in 2006. After this, the pathophysiology of FOP has been further elucidated through the efforts of research groups worldwide. In 2015, a workshop was held to gather these groups and discuss the new challenges in FOP research. Here we present an overview and update on these topics.

Cardiometabolic vigilance in COVID-19 and resource husbandry in resource-challenged times: Clinical practice- based expert opinion

BACKGROUND AND AIMS

The ongoing pandemic of coronavirus disease 2019 (COVID-19) is rapidly evolving, thereby posing a profound challenge to the global healthcare system. Cardiometabolic disorders are associated with poor clinical outcomes in persons with COVID-19. Healthcare challenges during the COVID-19 pandemic are linked to resource constraints including shortage of Personal Protective Equipment's (PPE), laboratory tests and medication. In this context, a group of clinical experts discussed the endocrine and cardiology vigilance required in times of COVID-19. Further, the group proposed certain resource husbandry recommendations to be followed during the pandemic to overcome the constraints.

METHOD

The clinical experts discussed and provided their inputs virtually. The expert panel included clinical experts comprising endocrinologists, Consultant Physicians and cardiologists from India. The panel thoroughly reviewed existing literature on the subject and proposed expert opinion.

RESULTS

The expert panel put forward clinical practice-based opinion for the management of cardiometabolic conditions including diabetes mellitus and hypertension. As these conditions are associated with poor clinical outcomes, the expert panel recommends that these persons be extra-cautious and take necessary precautions during the ongoing pandemic. Further, experts also provided appropriate, affordable, available and accessible solution to the resource constraint situations in times of COVID-19 pandemic.

CONCLUSION

The clinical expert opinion put forward in this article will serve as a reference for clinicians treating diabetes and cardiovascular disease during the COVID-19 pandemic.

Tackling the 3 Big Challenges Confronting Health Technology Assessment Development in Asia: A Commentary

There has been continuous development in the field of health technology assessment (HTA) owing to the added value of HTA in supporting healthcare reimbursement decisions. Collaboration and engagement among countries in Asia has been carried out to share experiences and learning on the barriers and factors facilitating the implementation and use of HTA in policy making. A symposium on the topic of Health Technology Assessment (HTA): Selecting the Highest Value Care was held on January 10, 2019 at the National University of Singapore, during which 3 major challenges confronting HTA development in Asia were identified. The symposium also offered possible ways to overcome the challenges.

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Countries in Asia increasingly recognize and adopt health technology assessment (HTA) in setting priorities for healthcare. Nevertheless, 2 common challenges can be identified, namely, lack of infrastructure and technical capacity to cope with the increasing demand for HTA, and the inadequate involvement of stakeholders in the HTA process.

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Solutions identified at the HTA symposium in Singapore to overcome these challenges were that countries should implement a tailored and transparent mechanism for using HTA, promote existing HTA capacity, and strengthen the understanding of HTA among the stakeholders.

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Health technology assessment symposia such as the one organized in Singapore provide a platform for countries to share knowledge and challenges, and bring different views to build into something greater and overcome the challenges. Such symposia should be organized regularly.

No Docs of All Trades: Ruling Reinforces Expert Witness Reforms

Before Texas' landmark liability reforms passed in 2003, gray areas in the law often led to serious green for people who sued physicians.

NO-FAULT COMPENSATION FOR MEDICAL INJURIES: TRENDS AND CHALLENGES

As an alternative to the tort or fault-based system, a no-fault compensation system has been viewed as having the potential to overcome problems inherent in the tort system by providing fair, speedy and adequate compensation for medically injured victims. Proponents of the suggested no-fault compensation system have argued that this system is more efficient in terms of time and money, as well as in making the circumstances in which compensation is paid, much clearer. However, the arguments against no-fault compensation systems are mainly on issues of funding difficulties, accountability and deterrence, particularly, once fault is taken out of the equation. Nonetheless, the no-fault compensation system has been successfully implemented in various countries but, at the same time, rejected in some others, as not being implementable. In the present trend, the no-fault system seems to fit the needs of society by offering greater access to justice for medically injured victims and providing a clearer "road map" towards obtaining suitable redress. This paper aims at providing the readers with an overview of the characteristics of the no fault compensation system and some examples of countries that have implemented it.

METHODOLOGY

Qualitative Research-Content Analysis.

RESULTS

Given the many problems and hurdles posed by the tort or fault-based system, it is questionable that it can efficiently play its role as a mechanism that affords fair and adequate compensation for victims of medical injuries. However, while a comprehensive no-fault compensation system offers a tempting alternative to the tort or fault-based system, to import such a change into our local scenario requires a great deal of consideration. There are major differences, mainly in terms of social standing, size of population, political ideology and financial commitment, between Malaysia and countries that have successfully implemented no-fault systems. Nevertheless, implementing a no-fault compensation system in Malaysia is not entirely impossible. A custom-made no-fault model tailored to suit our local scenario can be promising, provided that a thorough research is made, assessing the viability of a no-fault system in Malaysia, addressing the inherent problems and, consequently, designing a workable no-fault system in Malaysia.

[Errors in forensic medical activities]

The comparative structural and systemic analysis of 303 forensic medical expert conclusion (acts) made it possible to reveal and systematize errors encountered in forensic medical practice at the stages of investigation, interpretation, and estimation of the obtained results. The authors distinguish between performance errors and cognitive errors in the course of forensic medical expertise. The definition of the notion of "expert error" is proposed. The process of error analysis is described with special reference to forensic medical activities.

[The method for expert assessment as a tool for the improvement of the methodological basis of the activities of a bureau of forensic medical expertise]

An important aspect of the problem of iatrogenic poisoning is the lack of comprehensive relevant information. Many experts employed at the bureaus of forensic medical expertise believe that this problem can be resolved only based on a multifaceted approach. The results of questionnaire studies and cause-and-effect analysis allowed the following recommendations to be proposed for addressing the problem under consideration: making a minimal list of equipments necessary to maintain activities of forensic medical departments, updating the list of toxic substances to be studied in the laboratories of bureaus of forensic medical expertise, modification of the reporting form No 42 to be filled by such bureaus. The optimal approach is thought to be the equipment of all bureaus in compliance with the universal requirements, introduction of standard methods and technologies for the analysis of the materials included in the list of toxic substances to be determined.

[The data on statistical surveillance of recording forensic medical expertises of the harm to human health collected by the Bureau of Forensic Medical Expertise (BFME) in Central Health Department of the Moscow region]

This publication deals with the analysis of application of the "Medical criteria for the harm to human health" put into force on September 16, 2008, as exemplified by the work of the Bureau of forensic medical expertise (BFME), Central Health Department of the Moscow region, during the period from 2007 and 2010. The data were borrowed from the materials of departmental statistical reporting (F.42) on forensic medical examinations of the harm to human health carried out during the period between 2007 and 2010. In addition, the statistical report of BFME on the application of the medical criteria in 2010 was used. The number of forensic medical expertises for the estimation of the degree of harm to human health was shown to decrease by 9% but remain 3% higher than the average across the country. The number of expertises of severe harm to the health increased by 15% as in the whole of the country with the concomitant 20% reduction in the number expertises of mild and moderate harm. These trends are unrelated ether to the changes in the frequency of crimes leading to the serious harm to the health or to the number of subjects convicted of such crimes. It was found that p.p. 6.1.1 - 6.1.30 of the "Medical criteria" that list life-threatening injuries are most frequently (in 58% of the cases) used to document facts of severe harm to the health. The same is true of p.p. 6.11. - 6.11.11 listing the injuries responsible for the persistent loss of occupational capacity (by at least one third). The frequency of application of concrete paragraphs of the (Medical criteria, is determined within each group. The largest number of expert errors (3.2%) were committed while estimating serious harm to the health based on the paragraphs listing the injuries responsible for the persistent loss of occupational capacity (by at least one third). The minimal number of such errors (1%) were committed while estimating serious harm to the health from life-threatening injuries.

[The application of the medical criteria for the harm to health: expert and law-enforcement practice]

This paper is devoted to the practical application of the medical criteria (MC) for the harm to health (HH) put into force on September 16, 2008. The authors undertook the analysis of procedures of forensic medical expertises for the estimation of the harm to health during the periods before and after putting MC into action (between 2007 and 2010). The results of this analysis were compared with the number of documented criminal actions that caused harm to health and the number of subjects convicted of such crimes. It is shown that the frequency of crimes leading to the serious harm to health has increased (by 22%) in parallel to the roughly similar decrease in the frequency of crimes responsible for the moderate harm. These trends are unrelated to the changes in the number of subjects convicted of such crimes. The frequency of intentional infliction of the serious harm to health decreased by 12% and the number of subjects convicted of the crimes that caused serious (Criminal Code of the Russian Federation, parts 1-3, article 111) and moderate (Criminal Code, article 112) harm to health decreased in 2010 by 5% compared with 2007. The rise in the frequency of the crimes responsible for the serious harm to health (Medical Criteria, pp. 6.11.1-6.11.11) revealed during forensic medical expertises is unrelated to the number of documented crimes and subjects convicted of them under parts 1,2, article 264 of the Criminal Code. The number of documented crimes and subjects convicted of them after the new medical criteria had been put into force (2009 and 2010) decreased by 23% and 15% respectively. It is concluded that putting into effect the new regulations and medical criteria did not result in a substantial change in the relative frequency of the serious and moderate harm to health. Nor did the law enforcement practice gives evidence of any change in the relationship between cases of moderate and serious harm to health and in the number of grave crimes causing the harm to health. The new medical criteria allowed to put in order and present in a structured fashion the data on the harm to health depending on the degree of its severity.

[The main results of expert activities in the forensic biological departments of the bureau of forensic medical expertise of the Russian Federation for 2009]

This paper reports the main results of expert activities in the forensic biological departments of the Bureau of Forensic Medical Expertise of the Russian Federation for 2009. Analysis of expert data is supplemented by the comparison of the efficacy of the methods applied for the purpose of forensic medical studies. The information about the staff composition, material and technical support of the forensic biological departments is presented. A number of drawbacks have been revealed in the work of the forensic biological departments; recommendations are proposed for the improvement of their activities.

[The possibility of medico-legal opinionating on medical error in cases of waived postmortem examination]

For several years now, with the introduction of the health care sector reform we have been observing a considerable drop in the number of postmortem examinations performed in patients who died in hospitals. The decrease amounts to as much as 50 to 70%. This is undoubtedly a consequence of financial restrictions imposed on the management of these inpatient facilities. On the other hand, Departments of Forensic Medicine established to evaluate the so-called medical errors are swamped with an increasing avalanche of complaints concerning the appropriateness of therapeutic management. This leads to a growing number of orders from penal prosecution and jurisdiction agencies with requests for assessment whether a medical error has been committed in a particular case. The result of a postmortem examination is practically the only basis for a factual evaluation of a given case. When no autopsy has been performed, the experts are virtually helpless, and in the majority of such instances, they are forced to refuse passing an expert opinion. The report presents basic principles of medico-legal opinionating in criminal cases (including proceedings pertaining to medical errors), the rules governing the medical error assessment, as well as problems encountered in evaluating the appropriate course of treatment when a post mortem examination has been waived.

Forensic telepsychiatry in the United Kingdom

Forensic telepsychiatry remains in its infancy in the United Kingdom. This article sets out to describe how it can be used within a community forensic service, and the future challenges ahead in the United Kingdom. It looks at relevant academic, governmental, and legal resources and is designed as a scholarly reflection by clinicians rather than as a formal literature review.

Adjuvant strategies in breast cancer: new prospectives, questions and reflections at the end of 2007 St Gallen International Expert Consensus Conference

Breast cancer detection and staging are constantly evolving as technologies improve. Breast cancer surgery is also undergoing continuous refinement, with the objective being to achieve optimal cosmetic results. Surgery has been combined with intraoperative radiation therapy to achieve the best local-disease control with minimal side-effects. The adjuvant strategy of treatment is a 'hot' issue in this 'scenario'. Every 2 years at St Gallen, a nice and cold town in the north of Switzerland, more of 4000 breast cancer experts arrive from every part of the world, to improve their knowledge in this issue. The Consensus Conference with the discussion of 40 international panelists is the zenith of the conference. This report provides a brief presentation and reflections, immediately at the end of the conference, with the objective being to stimulate ideas regarding what should be done tomorrow.

[Paradigm of forensic medicine--trends of development]

The author addresses several issues concerning the current condition of forensic medicine and further trends of its development. One can believe that the split and the crisis of forensic medicine may result from the enfeeblement of its institutional character caused by changes to legal proceedings requirements. Disintegration seems to be also caused by strong subspecialty tendencies resulting from the progress and the increasing specialization in individual biological sciences forming a joint paradigm of forensic medicine, i.e. medico-legal toxicology, hemogenetics, histopathology and classic forensic medicine.

[Cases of suspected pediatric malpractice in casework material collected at the Department of Forensic Medicine, Medical University of Białystok in the years 2001-2006]

The authors analysed medico-legal opinions issued by teams of expert witnesses in the Department of Forensic Medicine, Medical University of Białystok. In the years 2001-2006 a total of 698 opinions in cases of suspected medical malpractice, including 44 (6.3%) pediatric cases, were issued. The opinions were ordered by police (9.3%) and prosecutors (90.7%). Medical malpractice was suspected in 20% of cases involving emergency procedures, 20% of cases involving family doctor's procedures and about 60% of cases involving hospital procedures. Medical malpractice was concluded in 9 (20.4%) cases, including 4 fatal demises.

The treating physician as expert witness: ethical and pragmatic considerations

OBJECTIVE

The objective of this analysis is to apprise pain physicians of the ethical concerns and practical considerations that arise when a treating physician is called upon to testify as an expert witness in a legal proceeding involving his or her own patient. The provision of expert testimony in medico-legal proceedings has come under heightened scrutiny in recent years. When a physician testifies as an expert witness, such testimony is considered to be the practice of medicine, and hence subject to the same ethical and professional obligations as patient care. Increasingly, medical professional organizations have promulgated guidelines for such activities, and even implemented oversight mechanisms to review complaints concerning expert testimony by their members. Additional issues are raised when the expert witness is also the treating physician for the patient who is a party to the legal proceeding in which the expert testimony is offered.

CONCLUSIONS

While it is not categorically unethical or inadvisable for a physician to testify as an expert witness in a medico-legal proceeding involving his or her own patient, such activity raises special issues and concerns. Prospective expert witnesses in such situations should be cognizant of these issues and insure that they have been adequately addressed before and during the testimony.

Psychiatric expert witnesses in the new millennium

We may anticipate changes in who is the expert in terms of gender, ethnicity, and professional discipline. We anticipate elaboration of training approaches. We foresee emergence of the "forensic tutor" role. We expect expansion of expert roles outside the courtroom. We expect demands for more constraint of expert roles, increased rigor, and empiric support. We expect vast expansion of technologic approaches to assessment and presentation. We expect evolution of ethical issues with preservation of core forensic values but changes in confidentiality, due process, and the nature of assessments. We expect extreme expansion of hard sciences in relation to understanding psychopathology.

Malpractice issues in neurological surgery

BACKGROUND

Malpractice litigation continues to be a serious problem in neurosurgery despite many suggestions to contain liability, including proposed federal legislation.

METHODS

A current study of 275 malpractice claims has been compared with a prior study of 300 cases of liability and potential liability reported in 1985. Twenty years later, the results are surprisingly similar. Spinal surgery continues to dominate neurosurgical malpractice claims with 42% of the total, most from lumbar spine operations. As in the previous study, trauma and intracranial surgery account for the next largest groups. Of particular significance in terms of improved diagnostic methodology were spinal operations at the wrong level as well as failure to diagnose sentinel bleeds, aneurysms, arteriovenous malformation, and other cerebral lesions.

RESULTS

Although many cases believed defensible were settled often because of significant neurological deficit, a number were dropped or dismissed after review, reports, or depositions, and defense verdicts were achieved in a similar number that went to trial.

CONCLUSIONS

Most plaintiff claims that had merit were settled. Although hope continues for tort reform, uniform capitation of noneconomic awards, and contingency fees, it should be noted that 119 claims, more than 40%, were considered either not defensible by defendants or had merit for the plaintiff.

Zur Stellung des sozialmedizinischen Experten im Medizinischen Dienst der Krankenversicherung (MDK) unter dem Einfluss sich wandelnder Anforderungen

The "Medical Services of the German Statutory Sickness Insurance Bodies (MDK)" is a non-profit organisation providing socio-medical specialist advice to the German Statutory Health and Nursing Care Insurances. Facing demographic changes as well as progress in medicine, highly qualified expertises and consultations are of increasing importance to manage the social security system and to continue to develop its structure. Sociomedical assignments of the MDK as applied health science is so far mainly related to individual aspects of insured persons (case management) but more and more to general aspects such as quality, consumer protection, efficiency, guiding concepts and organisation of the health care system. Based on its widespread experience, profound knowledge and confidence in its expertise the MDK is aware of its great sociopolitical responsibility and faces the wide range of assignments with regard to personneldevelopment and organisational innovations. Identification with principles of genuine medical practice, creating a modern job profile, and exercising creative power in accordance with the fundamental social legislation. This characterises the self-image and roleperception of medical experts of the MDK.

AMPK, the metabolic syndrome and cancer

The fuel-sensing enzyme 5'-AMP-activated protein kinase (AMPK) has a major role in the regulation of cellular lipid and protein metabolism in response to stimuli such as exercise, changes in fuel availability and the adipocyte-derived hormones leptin and adiponectin. Recent studies indicate that abnormalities in cellular lipid metabolism are involved in the pathogenesis of the metabolic syndrome, possibly because of dysregulation of AMPK and malonyl-CoA, a closely related molecule. As we discuss in this article, several findings also point to a link between AMPK and the growth and/or survival of some cancer cells. Thus, it has been demonstrated recently that the tumor suppressor LKB1 is a kinase that has a major role in phosphorylating and activating AMPK, and that another tumor suppressor, tuberous sclerosis complex 2, is phosphorylated and activated by AMPK. In addition, other studies indicate that mammalian homolog of target of rapamycin (mTOR), which has been implicated in the pathogenesis of insulin resistance and many types of cancer, is inhibited by AMPK.

Medication-overuse headache: similarities with drug addiction

Medication-overuse headache (MOH) is a clinically important entity and it is now well documented that the regular use of acute symptomatic medication by people with migraine or tension-type headache increases the risk of aggravation of the primary headache. MOH is one the most common causes of chronic migraine-like syndrome. In this article, we analyse the possible mechanisms that underlie sensitization in MOH by comparing these mechanisms with those reported for other forms of drug addiction. Moreover, the evidence for cognitive impulsivity in drug overuse in headache and in other forms of addiction associated with dysfunction of the frontostriatal system will be discussed. An integrative hypothesis for compulsive reward-seeking in MOH will be presented.

Overcoming limitations of natural anticancer drugs by combining with artificial agents

During a billion years of evolution, living creatures have perfected cytotoxic agents to kill other organisms without killing themselves, thus providing us with antibiotics to kill bacteria without killing eukaryotic (e.g. human) cells. Some natural agents inhibit specifically most vital cellular structures and functions in cancer cells. However, nature was not creating antibiotics for cancer, and natural agents kill cancer cells precisely because they share targets with normal cells. To discriminate between particular cancer cells and normal cells, we can design or select artificial agents that are not necessarily lethal but are aimed either at cancer-specific targets or at dispensable and even unavailable (in cancer cells) targets. Using rational drug combinations, such selective agents can assist natural agents to eradicate cancer cells selectively.

Why does the rapid delivery of drugs to the brain promote addiction?

It is widely accepted that the more rapidly drugs of abuse reach the brain the greater their potential for addiction. This might be one reason why cocaine and nicotine are more addictive when they are smoked than when they are administered by other routes. Traditionally, rapidly administered drugs are thought to be more addictive because they are more euphorigenic and/or more reinforcing. However, evidence for this is not compelling. We propose an alternative (although not mutually exclusive) explanation based on the idea that the transition to addiction involves drug-induced plasticity in mesocorticolimbic systems, changes that are manifested behaviourally as psychomotor and incentive sensitization. Recent evidence suggests that rapidly administered cocaine or nicotine preferentially engage mesocorticolimbic circuits, and more readily induce psychomotor sensitization. We conclude that rapidly delivered drugs might promote addiction by promoting forms of neurobehavioural plasticity that contribute to the compulsive pursuit of drugs.

Implementation of the Beers criteria: sticks and stones--or throw me a bone

Sticks and Stones Or Throw Me a Bone BOGSAT. While not very flattering, BOGSAT (Bunch of Old Guys Sitting Around Talking) accurately describes traditional decision making across many disciplines, including medicine. In an attempt to validate expert opinion panels using the BOGSAT method, the Evidence-Based Medicine (EBM) movement sprang up from the original writings of Dr. David Sackett and colleagues at McMaster University, Hamilton, Ontario. They defined EBM as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.

[Health, social, societal and organizational political effects of the implementation of the ICF on integrated rehabilitation--a vision of the conversion and its consequences]

Fundamental joint principles on expert opinions according to the social law code no. IX (SGB IX) and their application to a virtual individual case history were published recently in this journal. They are based on the ICF (International Classification of Functioning, Disability and Health, WHO 2001). A visionary review of the chances and prospects for the further development of the rehabilitative system is outlined and the necessary steps for their implementation are demonstrated.

Interdisciplinary telecommunication and expert teleconsultation in diagnostic pathology: present status and future prospects

Telepathology can be performed in an active or a passive manner. There are two main types: interdisciplinary telepathology and expert teleconsultations. Interdisciplinary telepathology involves a pathologist and another specialist (e.g. a radiologist or endoscopist). It is mainly used in an active manner (i.e. online and in realtime) and has three purposes: to ensure correct tissue sampling, to provide additional diagnostic information to the pathologist, or to facilitate collaborative therapeutic or diagnostic decision making between the clinician and pathologist. Expert teleconsultations, typically between two pathologists, are mainly undertaken in passive mode (i.e. offline and using store-and-forward techniques). The Internet often serves as a platform for both types of telepathology application. Experience with interdisciplinary telepathology is rare at present and is usually limited to partners at a local institution. The efficiency and accuracy of expert teleconsultations in telepathology have been demonstrated in numerous studies. In future, the application of expert teleconsultation in pathology will expand, with the Internet as the communications medium. Interdisciplinary telepathology is a promising technique to improve diagnostic quality.

The current status of microscopical hair comparisons

Although the microscopical comparison of human hairs has been accepted in courts of law for over a century, recent advances in DNA technology have called this type of forensic examination into question. In a number of cases, post-conviction DNA testing has exonerated defendants who were convicted in part on the results of microscopical hair comparisons. A federal judge has held a Daubert hearing on the microscopical comparison of human hairs and has concluded that this type of examination does not meet the criteria for admission of scientific evidence in federal courts. A review of the available scientific literature on microscopical hair comparisons (including studies conducted by the Royal Canadian Mounted Police and the Federal Bureau of Investigation) leads to three conclusions: (1) microscopical comparisons of human hairs can yield scientifically defensible conclusions that can contribute to criminal investigations and criminal prosecutions, (2) the reliability of microscopical hair comparisons is strongly affected by the training of the forensic hair examiner, (3) forensic hair examiners cannot offer estimates of the probability of a match of a questioned hair with a hair from a randomly selected person. In order for microscopical hair examinations to survive challenges under the U.S. Supreme Court's Daubert decision, hair microscopists must be better trained and undergo frequent proficiency testing. More research on the error rates of microscopical hair comparisons should be undertaken, and guidelines for the permissible interpretations of such comparisons should be established. Until these issues have been addressed and satisfactorily resolved, microscopical hair comparisons should be regarded by law enforcement agencies and courts of law as merely presumptive in nature, and all microscopical hair comparisons should be confirmed by nuclear DNA profiling or mitochondrial DNA sequencing.

[The status of the forensic biological service in the Russian Federation in 1997]

The main parameters of the activities of forensic biological departments are analyzed for the year 1997. The staff, number of experts, number of expert evaluations and objects of examination, and work load per staff expert are presented. Shortcomings in the activities of departments are enumerated and recommendations for improving the quality of expert evaluations are offered.