Surgeons find themselves on trial in forum featuring CMPA lawyers.
During a recent forum, Ontario surgeons learned that the courtroom requires a much different form of behaviour than the operating room. These lessons hit home during a mock trial featuring CMPA lawyers. (+info)
Relation of probability of causation to relative risk and doubling dose: a methodologic error that has become a social problem.
Epidemiologists, biostatisticians, and health physicists frequently serve as expert consultants to lawyers, courts, and administrators. One of the most common errors committed by experts is to equate, without qualification, the attributable fraction estimated from epidemiologic data to the probability of causation requested by courts and administrators. This error has become so pervasive that it has been incorporated into judicial precedents and legislation. This commentary provides a brief overview of the error and the context in which it arises. (+info)
American Society of Clinical Oncology technology assessment on breast cancer risk reduction strategies: tamoxifen and raloxifene.
OBJECTIVE: To conduct an evidence-based technology assessment to determine whether tamoxifen and raloxifene as breast cancer risk-reduction strategies are appropriate for broad-based conventional use in clinical practice. POTENTIAL INTERVENTION: Tamoxifen and raloxifene. OUTCOME: Outcomes of interest include breast cancer incidence, breast cancer-specific survival, overall survival, and net health benefits. EVIDENCE: A comprehensive, formal literature review was conducted for tamoxifen and raloxifene on the following topics: breast cancer risk reduction; tamoxifen side effects and toxicity, including endometrial cancer risk; tamoxifen influences on nonmalignant diseases, including coronary heart disease and osteoporosis; and decision making by women at risk for breast cancer. Testimony was collected from invited experts and interested parties. VALUES: More weight was given to publications that described randomized trials. BENEFITS/HARMS/COSTS: The American Society of Clinical Oncology (ASCO) Working Group acknowledges that a woman's decision regarding breast cancer risk-reduction strategies will depend on the importance and weight attributed to the information provided regarding both cancer and non-cancer-related risks. CONCLUSIONS: For women with a defined 5-year projected risk of breast cancer of >/= 1.66%, tamoxifen (at 20 mg/d for up to 5 years) may be offered to reduce their risk. It is premature to recommend raloxifene use to lower the risk of developing breast cancer outside of a clinical trial setting. On the basis of available information, use of raloxifene should currently be reserved for its approved indication to prevent bone loss in postmenopausal women. Conclusions are based on single-agent use of the drugs. At the present time, the effect of using tamoxifen or raloxifene with other medications (such as hormone replacement therapy), or using tamoxifen and raloxifene in combination or sequentially, has not been studied adequately. The continuing use of placebo-controlled trials in other risk-reduction trials highlights the current unanswered issues concerning the use of such interventions, especially when the influence on net health benefit remains to be determined. Breast cancer risk reduction is a rapidly evolving area. This technology assessment represents an ongoing process with existing plans to monitor and review data and to update recommendations in a timely matter. (See VALIDATION: The conclusions of the Working Group were evaluated by the ASCO Health Services Research Committee and by the ASCO Board of Directors. SPONSOR: American Society of Clinical Oncology. (+info)
A medico-legal review of some current UK guidelines in orthodontics: a personal view.
This article is a critical analysis from a medico-legal perspective of some current authoritative UK clinical guidelines in orthodontics. Two clinical guidelines have been produced by the Royal College of Surgeons of England and four by the British Orthodontic Society. Each guideline is published with the analysis immediately following it. Following recent UK case law (Bolitho v City & Hackney Health Authority, 1997) which allows the courts to choose between two bodies of responsible expert medical opinion where they feel one opinion is not 'logical', it is likely that the UK courts will increasingly turn to authoritative clinical guidelines to assist them in judging whether or not an appropriate standard of care has been achieved in medical negligence cases. It is thus important for clinicians to be aware of the recommendations of such guidelines, and if these are not followed the reasons should be discussed with the patient and recorded in the clinical case notes. This article attempts to highlight aspects of the guidelines that have medico-legal implications. (+info)
Repair of an inguinal hernia is one of the commonest operations undertaken by surgeons but the role of trauma in causing inguinal hernia is not well understood. This paper does not attempt to discuss the cause of inguinal hernia but seeks to analyse the cases which may be accepted by the Courts as being due to trauma. (+info)
Doctors on tribunals. A confusion of roles.
BACKGROUND: Mental health review tribunals are required to apply legal criteria within a clinical context. This can create tensions within both law and psychiatry. AIMS: To examine the role of the medical member of the tribunal as a possible mediator between the two disciplines. METHOD: Observation of tribunal hearings and panel deliberations and interviews with tribunal members were used to describe the role of the medical member. RESULTS: The dual roles imposed on the medical member as witness and decision-maker and as doctor and legal actor create formal demands and ethical conflicts that are hard, in practice, either to meet or to resolve. CONCLUSIONS: The structure for providing tribunals with access to expert psychiatric input and advice requires reconsideration. (+info)
Evaluation of new online automated embolic signal detection algorithm, including comparison with panel of international experts.
BACKGROUND AND PURPOSE: The clinical application of Doppler detection of circulating cerebral emboli will depend on a reliable automated system of embolic signal detection; such a system is not currently available. Previous studies have shown that frequency filtering increases the ratio of embolic signal to background signal intensity and that the incorporation of such an approach into an offline automated detection system markedly improved performance. In this study, we evaluated an online version of the system. In a single-center study, we compared its performance with that of a human expert on data from 2 clinical situations, carotid stenosis and the period immediately after carotid endarterectomy. Because the human expert is currently the "gold standard" for embolic signal detection, we also compared the performance of the system with an international panel of human experts in a multicenter study. METHODS: In the single-center evaluation, the performance of the software was tested against that of a human expert on 20 hours of data from 21 patients with carotid stenosis and 18 hours of data from 9 patients that was recorded after carotid endarterectomy. For the multicenter evaluation, a separate 2-hour data set, recorded from 5 patients after carotid endarterectomy, was analyzed by 6 different human experts using the same equipment and by the software. Agreement was assessed by determining the probability of agreement. RESULTS: In the 20 hours of carotid stenosis data, there were 140 embolic signals with an intensity of > or =7 dB. With the software set at a confidence threshold of 60%, a sensitivity of 85.7% and a specificity of 88.9% for detection of embolic signals were obtained. At higher confidence thresholds, a specificity >95% could be obtained, but this was at the expense of a lower sensitivity. In the 18 hours of post-carotid endarterectomy data, there were 411 embolic signals of > or =7-dB intensity. When the same confidence threshold was used, a sensitivity of 95.4% and a specificity of 97.5% were obtained. In the multicenter evaluation, a total of 127 events were recorded as embolic signals by at least 1 center. The total number of embolic signals detected by the 6 different centers was 84, 93, 108, 92, 63, and 78. The software set at a confidence threshold of 60% detected 90 events as embolic signals. The mean probability of agreement, including all human experts and the software, was 0.83, and this was higher than that for 2 human experts and lower than that for 4 human experts. The mean values for the 6 human observers were averaged to give P=0.84, which was similar to that of the software. CONCLUSIONS: By using the frequency specificity of the intensity increase occurring with embolic signals, we have developed an automated detection system with a much improved sensitivity. Its performance was equal to that of some human experts and only slightly below the mean performance of a panel of human experts (+info)
Government laboratory worker with lung cancer: comparing risks from beryllium, asbestos, and tobacco smoke.
Occupational medicine physicians are frequently asked to establish cancer causation in patients with both workplace and non-workplace exposures. This is especially difficult in cases involving beryllium for which the data on human carcinogenicity are limited and controversial. In this report we present the case of a 73-year-old former technician at a government research facility who was recently diagnosed with lung cancer. The patient is a former smoker who has worked with both beryllium and asbestos. He was referred to the University of California, San Francisco, Occupational and Environmental Medicine Clinic at San Francisco General Hospital for an evaluation of whether past workplace exposures may have contributed to his current disease. The goal of this paper is to provide an example of the use of data-based risk estimates to determine causation in patients with multiple exposures. To do this, we review the current knowledge of lung cancer risks in former smokers and asbestos workers, and evaluate the controversies surrounding the epidemiologic data linking beryllium and cancer. Based on this information, we estimated that the patient's risk of lung cancer from asbestos was less than his risk from tobacco smoke, whereas his risk from beryllium was approximately equal to his risk from smoking. Based on these estimates, the patient's workplace was considered a probable contributing factor to his development of lung cancer. (+info)