Organisational barriers and facilitators to the implementation of best practices within paediatric forensic radiographic practice - A scoping review.

INTRODUCTION: Implementation and application of evidence-based practice through legislation, international and national guidelines and local protocols is integral to the successful undertaking of forensic radiographic practice, because of its medico-legal role. This research aims to evaluate those organisational barriers and facilitators to its effective implementation. METHODS: This scoping review was undertaken according to the JBI updated guidelines using the PCC mnemonic. A systematic search of 10 databases was undertaken to identify literature addressing the research question relating to this aspect of forensic radiography practice. Handsearching and snowballing were also included to enhance this search strategy. The search focussed on forensic imaging of paediatrics, the living and deceased. RESULTS: Of the 301 papers initially selected, 9 articles were identified as eligible for inclusion, encompassing an international perspective. Through Inductive Content Analysis, 5 conceptual categories were developed: ineffective organisational governance, education translation, system brakes, default practice, and value-based judgement. CONCLUSION: The results indicate that there are many complex and multifactorial organisational issues impacting upon effective implementation of best practices within paediatric forensic imaging. There is a need to address these issues, before attempting strategies for future implementation. It is essential to recognise that there can be no one-size-fits approach, but rather tailored strategies are required recognising individual needs within the multi-disciplinary scope of forensic radiographic practice. IMPLICATIONS FOR PRACTICE: Failure to recognise and address the identified issues impacting upon effective implementation, may have significant implications on the processes and individuals involved in the forensic imaging acquisition pathway. Successful addressing of these issues may enable the professionals involved in organisational governance to create a more conducive and receptive environment for best-practice implementation.

Half Century Since SIDS: A Reappraisal of Terminology.

After a sudden infant death, parents and caregivers need accurate and open communication about why their infant died. Communicating tragic news about a child's death to families and caregivers is difficult. Shared and consistent terminology is essential for pediatricians, other physicians, and nonphysician clinicians to improve communication with families and among themselves. When families do not have complete information about why their child died, pediatricians will not be able to support them through the process and make appropriate referrals for pediatric specialty and mental health care. Families can only speculate about the cause and may blame themselves or others for the infant's death. The terminology used to describe infant deaths that occur suddenly and unexpectedly includes an assortment of terms that vary across and among pediatrician, other physician, or nonphysician clinician disciplines. Having consistent terminology is critical to improve the understanding of the etiology, pathophysiology, and epidemiology of these deaths and communicate with families. A lack of consistent terminology also makes it difficult to reliably monitor trends in mortality and hampers the ability to develop effective interventions. This report describes the history of sudden infant death terminology and summarizes the debate over the terminology and the resulting diagnostic shift of these deaths. This information is to assist pediatricians, other physicians, and nonphysician clinicians in caring for families during this difficult time. The importance of consistent terminology is outlined, followed by a summary of progress toward consensus. Recommendations for pediatricians, other physicians, and nonphysician clinicians are proposed.

Does peer consultation between forensic physicians reduce inter-doctor variation when issuing medical death certifications?

INTRODUCTION: Because earlier research showed that inaccuracies were observed in the interpretation and handling of deaths by forensic physicians, peer consultation among forensic physicians was introduced before advice was given to treating physicians calling for advice. In addition, peer consultation was introduced as a means to improve the correctness of conclusions concerning the manner of death when performing external post-mortem examinations. METHOD: In the period of November 2017 until April 2018 all reports of external postmortem examinations (n = 498) and all telephonic consultations between treating physicians with forensic physicians, concerning postmortem examinations (n = 167), were analyzed retrospectively. RESULTS: Peer consultation among forensic physicians took place in 70% of the 167 telephonic consultations initiated by treating physicians. In 92% of all cases of telephonic consultation, the accurateness of advice to treating physicians was deemed accurate. In 67% (n = 498) of all external postmortem examinations in the study period, peer consultation between forensic physicians took place. The conclusion regarding the manner of death after external postmortem examination was accurate in 99% of all cases (n = 491 out of 498). CONCLUSION: The advices given by forensic physicians to treating physicians have improved after the introduction of peer consultation among forensic physicians. Peer consultation therefore should be recommended as a means for quality assurance.

Looking for Post-Mortem Metabolomic Standardization: Waiting for Godot-The Importance of Post-Mortem Interval in Forensic Metabolomics.

A growing body of evidence suggests that the post-mortem interval exerts a strong effect on the metabolome, independently of the biological matrix or the cause of death. A sound and shared approach in standardization is mandatory.

Not discussed: Inequalities in narrative text data for suicide deaths in the National Violent Death Reporting System.

BACKGROUND: The rate of suicide in the US has increased substantially in the past two decades, and new insights are needed to support prevention efforts. The National Violent Death Reporting System (NVDRS), the nation's most comprehensive registry of suicide mortality, has qualitative text narratives that describe salient circumstances of these deaths. These texts have great potential for providing novel insights about suicide risk but may be subject to information bias. OBJECTIVE: To examine the relationship between decedent characteristics and the presence and length of NVDRS text narratives (separately for coroner/medical examiner (C/ME) and law enforcement (LE) reports) among 233,108 suicide and undetermined deaths from 2003-2017. METHODS: Generalized estimating equations (GEE) logistic and quasi-Poisson modeling was used to examine variation in the narratives (proportion of missing texts and character length of the non-missing texts, respectively) as a function of decedent age, sex, race/ethnicity, education, marital status, military history, and homeless status. Models adjusted for site, year, location of death, and autopsy status. RESULTS: The frequency of missing narratives was higher for LE vs. C/ME texts (19.8% vs. 5.2%). Decedent characteristics were not consistently associated with missing text across the two types of narratives (i.e., Black decedents were more likely to be missing the LE narrative but less likely to be missing the C/ME narrative relative to non-Hispanic whites). Conditional on having a narrative, C/ME were significantly longer than LE (822.44 vs. 780.68 characters). Decedents who were older, male, had less education and some racial/ethnic minority groups had shorter narratives (both C/ME and LE) than younger, female, more educated, and non-Hispanic white decedents. CONCLUSION: Decedent characteristics are significantly related to the presence and length of narrative texts for suicide and undetermined deaths in the NVDRS. Findings can inform future research using these data to identify novel determinants of suicide mortality.

Characteristics and scope of humanitarian relief forensic medical evaluations for immigrant children in the US.

According to US Customs and Border Protection, over 473,000 family units and 76,000 unaccompanied children were apprehended in 2019, a multi-fold increase from previous years. Thus, the number of children who may be eligible for humanitarian relief has increased significantly. For those claiming humanitarian relief, forensic medical evaluations performed by health professionals can provide critical evidence to bolster claims. In this cross-sectional, nationwide survey-in which we sought to characterize specialties, forensic training, capacity, and scope of humanitarian relief evaluations for immigrant children under eighteen-years-old-only 28 providers, half of whom were Child Abuse Pediatricians, reported performing humanitarian relief evaluations. The most common reported type of humanitarian relief evaluation conducted was for asylum. We found that the current training for forensic medical evaluations for humanitarian relief in pediatrics is likely varied not well-defined, and not pediatric-specific. In order to protect the rights of children who are eligible for humanitarian relief, pediatric and family medicine forensic medical evaluation training standards and curricula need to be developed; validated humanitarian relief screening tools need to be tested and utilized; and residents and attending physicians, including specialists with expertise in forensic evaluations, need to be actively recruited to perform these evaluations in collaboration with legal aid organizations.

Update on the Diagnostic Pitfalls of Autopsy and Post-Mortem Genetic Testing in Cardiomyopathies.

Inherited cardiomyopathies are frequent causes of sudden cardiac death (SCD), especially in young patients. Despite at the autopsy they usually have distinctive microscopic and/or macroscopic diagnostic features, their phenotypes may be mild or ambiguous, possibly leading to misdiagnoses or missed diagnoses. In this review, the main differential diagnoses of hypertrophic cardiomyopathy (e.g., athlete's heart, idiopathic left ventricular hypertrophy), arrhythmogenic cardiomyopathy (e.g., adipositas cordis, myocarditis) and dilated cardiomyopathy (e.g., acquired forms of dilated cardiomyopathy, left ventricular noncompaction) are discussed. Moreover, the diagnostic issues in SCD victims affected by phenotype-negative hypertrophic cardiomyopathy and the relationship between myocardial bridging and hypertrophic cardiomyopathy are analyzed. Finally, the applications/limits of virtopsy and post-mortem genetic testing in this field are discussed, with particular attention to the issues related to the assessment of the significance of the genetic variants.

Cardiac tamponade and its medicolegal aspects: A case report.

Cardiac tamponade is a life-threatening emergency having both acute and a delayed presentation. In the latter there is a potential for medical practitioners to miss the diagnosis as happened in our case resulting in allegations of medical negligence. Before starting the autopsy in such cases, the forensic pathologist should try to obtain the complete treatment record and be ready to request ancillary investigations as required. We report a case of death due to cardiac tamponade caused by a penetrating injury to the heart. A feature of this case was the failure of our medical system to diagnose the condition and the legal system due to failure of the police to register the first information report under appropriate legal sections.

Life-threatening danger assessments of penetrating injuries in Eastern Danish clinical forensic medicine.

Clinical forensic assessments of injuries' life-threatening danger may have an impact on the legal aftermath following a violent assault. The pursuit of evidence-based guidelines should ensure a user-independent and reproducible forensic practice. However, does it? The aim of this study was to evaluate the forensic life-threatening danger assessments after a protocol implementation in 2016. The evaluation concerned usability and reproducibility of the protocol, and its influence on assessment severity. We analyzed the level of inter- and intra-rater agreement using 169 blinded, prior-protocol cases that were reassessed by two forensic specialists. We compared assessment made the year before and after protocol implementation (n = 262), and the forensic specialists' reassessments with the prior-protocol cases' original assessments (n = 169). Whether to make an assessment, the levels of agreement varied between weak agreement (inter-rater, Κ = 0.43; assessor 1, Κ = 0.57) and strong agreement (assessor 2, Κ = 0.90). Regarding severity, the levels of agreement varied between strong agreement (inter-rater, Κ = 0.87; assessor 1: Κ = 0.90) and almost perfect agreement (assessor 2: Κ = 0.94). The assessments were statistically significant redistributed after the implementation (chi-square test: p < 0.0001). The proportion of cases assessed as having not been in life-threatening danger increased from 9 to 43%, and moderate severity assessments decreased from 55 to 23%. Of the moderate severity assessments, 55% were reassessed as having not been in life-threatening danger. The protocol ensured independent and reproducible assessments when the forensic specialists agreed on making one. The protocol resulted in less severe assessments. Future studies should examine the reliability of the protocol and its consequences for legal aftermaths.

Forensic evaluation of alleged wrist restraint/handcuff injuries in survivors of torture utilizing the Istanbul Protocol.

Despite being a common form of abuse, there is a paucity of literature describing shackling and wrist restraint injuries among survivors of torture. Forensic evaluation of alleged wrist restraint/handcuff injuries in survivors of torture presents challenges to the evaluator, especially if the injuries are remote and do not leave lasting marks nor neurologic deficits. Thorough history-taking and physical examination are critical to effective forensic documentation. Guidance is provided in The Manual on Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (Istanbul Protocol), the gold standard for the medicolegal documentation of torture. This guidance relies primarily on physical findings, with less direction provided on how to interpret historical evidence or when historical evidence provided by the patient can be interpreted as highly consistent with alleged injury in the absence of current physical findings. Through a case-based review, we present diagnostic strategies for the evaluation of alleged abuse involving wrist restraints/handcuffs, focusing on skin, neurologic, and osseous injuries. We highlight key findings from both the history and physical examination that will allow the evaluator to improve the accuracy of their expert medical opinion on the degree to which medical findings correlate with the patient's allegations of wrist restraint injuries.

Perils of human remains examination in COVID-19 times.

The novel coronavirus, SARS-CoV-2 has surged globally bringing the whole world virtually to a standstill. Due to its highly contagious nature, various guidelines, protocols and preventive strategies have been devised for the safety of healthcare workers during management of the living as well as the dead. However, guidelines and precautions to be followed during the examination of the human skeletal remains are largely lacking. The present communication intends to address the issue of safe handling of human remains during medicolegal investigations in the COVID-19 pandemic times.

INFERENCE: An Evidence-Based Approach for Medicolegal Causal Analyses.

A fundamental purpose of forensic medical, or medicolegal, analysis is to provide legal factfinders with an opinion regarding the causal relationship between an alleged unlawful or negligent action and a medically observed adverse outcome, which is needed to establish legal liability. At present, there are no universally established standards for medicolegal causal analysis, although several different approaches to causation exist, with varying strengths and weaknesses and degrees of practical utility. These approaches can be categorized as intuitive or probabilistic, which are distributed along a spectrum of increasing case complexity. This paper proposes a systematic approach to evidence-based assessment of causation in forensic medicine, called the INtegration of Forensic Epidemiology and the Rigorous EvaluatioN of Causation Elements (INFERENCE) approach. The INFERENCE approach is an evolution of existing causal analysis methods and consists of a stepwise method of increasing complexity. We aimed to develop a probabilistic causal analysis approach that (1) fits the needs of legal factfinders who require an estimate of the probability of causation, and (2) is still sufficiently straightforward to be applied in real-world forensic medical practice. As the INFERENCE approach is most relevant in complex cases, we also propose a process for selecting the most appropriate causal analysis method for any given case. The goal of this approach is to improve the reproducibility and transparency of causal analyses, which will promote evidence-based practice and quality assurance in forensic medicine, resulting in expert opinions that are reliable and objective in legal proceedings.

Proposal for a harmonized protocol for COVID-19 screening and necropsy in forensic sciences facilities.

On 31 December 2019, health authorities in the People's Republic of China informed the World Health Organization of a then limited outbreak of interstitial viral pneumonia, identified at a laboratory in the city of Wuhan. In mid-April 2020 this outbreak of COVID-19 (as the disease has been called) has aggravated and spread worldwide, causing more than 200,000 deaths and affecting especially the United States, Spain, Italy, France and the United Kingdom. Despite the severity of the outbreak, the pathological findings have not been described in detail and there are very few guidelines or protocols for conducting autopsy studies on patients who have died from COVID-19. There are currently very few histopathological case series studies on this disease. In addition, some of these studies have been performed on biopsies or surgical resection pieces from patients in whom disease was subsequently demonstrated or through minimally invasive autopsy protocols. None of the studies offer a detailed necropsy protocol. This document proposes a protocol of action for the institutes of Forensic Medicine facing the current SARS-CoV2 pandemic, which combines protection of worker safety with optimization of tissue collection.

Pre-validation of a MALDI MS proteomics-based method for the reliable detection of blood and blood provenance.

The reliable identification of blood, as well as the determination of its origin (human or animal) is of great importance in a forensic investigation. Whilst presumptive tests are rapid and deployed in situ, their very nature requires confirmatory tests to be performed remotely. However, only serological tests can determine blood provenance. The present study improves on a previously devised Matrix Assisted Laser Desorption Ionisation Mass Spectrometry (MALDI MS)-proteomics based method for the reliable detection of blood by enabling the determination of blood provenance. The overall protocol was developed to be more specific than presumptive tests and faster/easier than the gold standard liquid chromatography (LC) MS/MS analysis. This is considered a pre-validation study that has investigated stains and fingermarks made in blood, other biofluids and substances that can elicit a false-positive response to colorimetric or presumptive tests, in a blind fashion. Stains and marks were either untreated or enhanced with a range of presumptive tests. Human and animal blood were correctly discriminated from other biofluids and non-biofluid related matrices; animal species determination was also possible within the system investigated. The procedure is compatible with the prior application of presumptive tests. The refined strategy resulting from iterative improvements through a trial and error study of 56 samples was applied to a final set of 13 blind samples. This final study yielded 12/13 correct identifications with the 13th sample being correctly identified as animal blood but with no species attribution. This body of work will contribute towards the validation of MALDI MS based methods and deployment in violent crimes involving bloodshed.

Emergency Department Management of the Sexual Assault Victim in the COVID Era: A Model SAFET-I Guideline From San Diego County.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has contributed to an increase in intimate partner violence (IPV), posing challenges to health care providers who must protect themselves and others during sexual assault examinations. Victims of sexual assault encountered in prehospital and emergency department (ED) settings have legal as well as medical needs. A series of procedures must be carefully followed to facilitate forensic evidence collection and law enforcement investigation. A literature review detected a paucity of published guidance on the management of sexual assault patients in the ED, and no information specific to COVID-19. OBJECTIVE: Investigators sought to update the San Diego County sexual assault guidelines, created in collaboration with health care professionals, forensic specialists, and law enforcement, through a consensus iterative review process. An additional objective was to create a SAFET-I Tool for use by frontline providers during the COVID-19 pandemic. DISCUSSION: The authors present a novel SAFET-I Tool that outlines the following five components of effective sexual assault patient care: stabilization, alert system activation, forensic evidence consideration, expedited post-assault treatment, and trauma-informed care. This framework can be used as an educational tool and template for agencies interested in developing or adapting existing sexual assault policies. CONCLUSIONS: There is a lack of clinical guidance for ED providers that integrates the many aspects of sexual assault patient care, particularly during the COVID-19 pandemic. A SAFET-I Tool is presented to assist emergency health care providers in the treatment and advocacy of sexual assault patients during a period with increasing rates of IPV.

Role of clinical forensic medicine unit in quality and standardization of medico-legal reports.

INTRODUCTION: Incomplete and inaccurate medico-legal report (MLR) often slow down the court trials and lead to incorrect judgments. Identification of such mistakes and shortcomings in the report can help in preventing litigations against doctors, unbiased court judgments, and injustice. Clinical Forensic Medicine Unit (CFMU) deals with all medico-legal cases (MLC) brought to the institution. It prepares MLR's, collect evidence, and supervises medicolegal issues of the institute. MATERIAL & METHOD: Pre-CFMU included 50 poisoning and 50 non-poisoning reports, selected randomly among 504 cases. Post-CFMU also included 50 poisoning and 50 non-poisoning reports, which were chosen randomly among total 588 cases. RESULT: Comparing the pre and post CFMU non-poisoning reports, the following parameters were statistically significant; date and time of examination, address of the patient, details of accompanied police, details of attendant, identification marks, history of incidence, consent, description, dimension, location and age of injuries, pictorial presentation, general condition of the patient on arrival, and final opinion. Comparing the pre and post CFMU poisoning reports, statistically significant results were obtained for the following parameters; address of the patient, identification marks, history of incidence, consent, general condition of the patient on arrival, details of evidence collected, preservative used, seal status, and final opinion. CONCLUSION: The present study concludes that the errors were significantly reduced in medico-legal reports prepared by forensic experts. It is, therefore, necessary to employ forensic experts at every healthcare facility not only to prevent lawsuits but also to strengthen the judiciary. Additionally, we recommend regular training of non-forensic professionals to acquaint them with medico-legal work.

DNA evidence in sexual assault cases in Pakistan.

Sexual assault is becoming a global epidemic, affecting close to a billion women throughout the world. This paper explores the challenges in the admissibility of DNA evidence in rape cases in Pakistan. Delays in the medical examination of victims, and improper collection and packaging of evidentiary material, compromise the probative biological evidence. In the last few years, existing laws have been amended to increase the utility of DNA evidence during criminal trials. However, various issues - for example lack of proper knowledge of DNA evidence by lawyers and judicial officers, inadequacies in existing laws and conflicting decisions of apex courts - can affect the admissibility of DNA evidence during criminal trials.