Medicolegal Implications Research Articles

The Morbidity and Mortality Review: A crucial tool for improving patient safety and quality

Institutional mortality rates can be used to monitor the quality of hospital care. Morbidity and Mortality (M&M) review is crucial to the hospital’s quality and patient safety initiatives. A multi-disciplinary forum to discuss M&M better lends itself to the discussion that balances physician error and system failure. It is crucial to afford attendees opportunities for introspection/reflection while holding those responsible accountable without apportioning blame. This review was undertaken at the M&M conference conducted by the Department of Surgery at The Aga Khan University Hospital Nairobi, a tertiary teaching and referral hospital. All surgical residents and faculty attend the M&M conference. A standard reporting format is used for every case discussed at the departmental level and shared at the institutional level. Morbidities and Mortalities that are analyzed as being due to a system or administrative process failure or having potential medico-legal implications are subjected to a Root Cause Analysis. Recommendations from individual cases focus on measures that can prevent similar outcomes or adverse incidents or improve the care processes provided to this group of patients. These recommendations should resist the temptation to apportion blame to individuals. The department needs to construct the meetings to integrate the system and administrative issues underlying unexpected outcomes and discuss technical/clinical-related issues. Physicians who feel they work in a ‘safe’ environment are likelier to self-report events and offer them for discussion.

Clinical Applications, Legal Considerations and Implementation Challenges of Smartphone-Based Thermography: A Scoping Review

Medical thermography is a non-invasive technique that allows the measurement of the temperature of the human body surface, exploiting the heat emitted by the body through the skin in the form of infrared electromagnetic radiation. Recently, smartphone-based thermography (ST) has drawn considerable attention. This scoping review (SR) aims to describe its current applications and reliability based on currently available research findings, also taking into account the medico-legal implications linked to its use. A search of the sources was conducted on multiple databases (PubMed, Scopus, Cochrane, Lilacs, Google Scholar). Based on a set of eligibility criteria, all articles deemed useful were included in the SR. Collected data, processed with descriptive statistics, are then discussed. From the initial 241 results, after duplicate removal and full-text reading based on inclusion/exclusion criteria, 20 articles were classified according to the main characteristics and indications and outcomes are highlighted based on clinical evidence. The most frequently documented fields of ST are wound care management and vascular surgery. Other disciplines are less explored (dentistry, ophthalmology, otorhinolaryngology, orthopedics, etc.). Practicality, operational simplicity and affordability of mobile thermographic devices are the chief strengths of this technology. Comparative studies with traditional thermal imaging methods are poor in terms of the number of patients analyzed but this technology showed high sensitivity and accuracy in the large number of patients enrolled in observational studies, encouraging the development of further operational protocols in all medical specialties. Gaining a deeper understanding of such techniques will also help settle the medico-legal issues which may arise from the clinical implementation of ST, thus appraising its reliability and safety from that perspective as well.

Whole Slide Imaging, Artificial Intelligence, and Machine Learning in Pediatric and Perinatal Pathology: Current Status and Future Directions

The integration of artificial intelligence (AI) into healthcare is becoming increasingly mainstream. Leveraging digital technologies, such as AI and deep learning, impacts researchers, clinicians, and industry due to promising performance and clinical potential. Digital pathology is now a proven technology, enabling generation of high-resolution digital images from glass slides (whole slide images; WSI). WSIs facilitates AI-based image analysis to aid pathologists in diagnostic tasks, improve workflow efficiency, and address workforce shortages. Example applications include tumor segmentation, disease classification, detection, quantitation and grading, rare object identification, and outcome prediction. While advancements have occurred, integration of WSI-AI into clinical laboratories faces challenges, including concerns regarding evidence quality, regulatory adaptations, clinical evaluation, and safety considerations. In pediatric and developmental histopathology, adoption of AI could improve diagnostic efficiency, automate routine tasks, and address specific diagnostic challenges unique to the specialty, such as standardizing placental pathology and developmental autopsy findings, as well as mitigating staffing shortages in the subspeciality. Additionally, AI-based tools have potential to mitigate medicolegal implications by enhancing reproducibility and objectivity in diagnostic evaluations. An overview of recent developments and challenges in applying AI to pediatric and developmental pathology, focusing on machine learning methods applied to WSIs of pediatric pathology specimens is presented.

Telehealth Use and Legal Considerations in Drug Health Services During Pandemics: Systematic Scoping Review.

The COVID-19 pandemic impacted patients with substance use disorder (SUD) more than the general population and resulted in substantially increased emergency department admissions. Routine care of patients attending drug health services during the pandemic transitioned, with telehealth being important in delivering appropriate care. However, telehealth introduces unique risks such as privacy, confidentiality, and data safety. Providing health care through telehealth may fail if the legal impacts are not fully identified and acted on by health professionals. It also poses unintended risks for patients and can result in ineffectiveness, damages, medical negligence, and detracts from the best intentions of governments and health professionals. Understanding the legal framework ensures that medical professionals operate health care through telehealth within the law. Providing health care successfully through telehealth depends on the balance between innovation and legal compliance. By considering these aspects, clinicians and practitioners can provide effective and safe telehealth services during pandemics or any other natural disaster. We aimed to explore the legal impact of autonomy consent, confidentiality, privacy, data security, professional indemnity, and liability when delivering telehealth to patients with SUD. The scoping review also aimed to provide legal, ethical, and clinical considerations to minimize legal risks with using telehealth in drug health service outpatient settings. We performed a scoping review to provide an overview of existing research, statutes, and case laws for the incorporation of clinical, ethical, and legal considerations into telehealth use. Six databases for medical and 6 databases for legal publications were searched, as well as Australian national and selected international regulatory standards. Medical articles published up to June 2022 were included in this review. Our search yielded 1436 publications, 614 abstracts were reviewed, and 80 published studies met the inclusion criteria from 614 legal and medical search results. Current regulations related to technology use in drug health services, relevant cases, and international regulatory standards are discussed. In total, 43 legal documents including 15 statutes, 4 case laws, and 37 medical publications were reviewed. The themes arising from the literature were consent and autonomy (20/80, 25%), confidentiality (8/80, 10%), privacy (8/80, 10%), data security (7/80, 9%), and professional indemnity issues (3/80, 4%) in telehealth use. Further, 24 studies identified legal issues associated with telehealth use in patients with SUD. Our review identified potential legal issues associated with telehealth use in patients with SUD. Several legal and medical research articles provide frameworks, codes of conduct, or suggestions for clinicians to consider, but there was little discussion or evidence of how legal considerations are being applied when providing telehealth consultations at drug health services. Clinicians should be aware of the medicolegal implications when providing health care via telehealth at drug health services.

Evaluation of two scoring systems assessing the epiphyseal union at shoulder joint as predictors of chronological age among a sample of Egyptians

Age estimation has extensive medicolegal implications in civil and criminal identification. Despite the surge in adopting radiological investigations to assess developmental bony changes, the shoulder joint is understudied. A cross-sectional study was conducted, enrolling 283 shoulder radiographs of Egyptians, investigating the reliability of two previously established scores as predictors of chronological age using the epiphyseal maturation of proximal humerus and acromion process. Epiphyseal union of proximal humerus commenced at age of 16.1–17 and completed around 21, while complete acromial union was observed around the age of 20.8. Females significantly preceded males and showed lower mean total Scores A and B at different maturation stages. There was a significant strong positive correlation between the chronological age and the epiphyseal maturation of humerus, acromion and total shoulder scores with correlation coefficients between 0.84 and 0.9. The receiver operating characteristic curves showed significant discriminating power of the total shoulder Scores A and B as predictors of the ages of 14 and 16, with area under curves above 0.9, minimal accuracy of 96.5 % and p values of 0.001. Six proposed models were established where the model “age = 0.318 + (0.388) total shoulder Score A + (2.842) total shoulder Score B + 1.931 (sex)” showed the best significant prediction power of radiographic evaluation of epiphyseal maturation in the proximal humerus and acromion in estimating the ages between 8 and around 20 years (R2 of 0.812). Applying this model to assess the chronological age, especially if the results from the hand and teeth are inconclusive, is promising.

Penile curvature severity in patients with Peyronie's disease does not correlate with dynamic color doppler duplex ultrasound parameters: findings from a real-life cross-sectional study.

There is inconsistent data regarding the possible inaccuracies in dynamic penile color Doppler duplex ultrasound (CDDU) measurements in men with penile curvature because of Peyronie's disease (PD). We sought to explore the relationship between the degree of penile curvature and CDDU parameters in men with PD. Comprehensive data from 154 consecutive men presenting with PD as their primary complaint at a single academic center were prospectively collected and analyzed. All men underwent CDDU. Penile curvature was measured using a goniometer at time of maximum erection during CDDU. Patients were grouped based on CDDU parameters into-normal (average peak systolic velocity [PSV] ≥ 35cm/s and resistance index [RI] ≥ 0.85) and pathological CDDU (average PSV<35cm/s and/or RI<0.85). Descriptive statistics was used to compare the two subcohorts. Linear regression models were fitted to explore the association between the degree of penile curvature and dynamic CDDU parameters. Overall, the median interquartile range (IQR) age was 56 (48-63) years. The median (IQR) PSV and degree of penile curvature were 48.8cm/s (37.9-58.5) and 40 degrees (30-60), respectively. At CDDU, the degrees of penile curvature were as follows: 10-30 degrees in 63 (40.9%) men, 30-70 degrees in 70 (45.5%) men, and 70-90 degrees in 21 (13.6%) men, respectively. Of all, 116 (75.3%) patients showed a PSV>35cm/s and RI ≥ 0.85. Patients with pathologic vs. normal CDDU parameters did not differ in median (IQR) curvature (32.5° [30°-58.7°] vs. 40° [30°-65°], p=0.5) or in the distribution across curvature range groups. Linear regression analysis revealed that the degree of penile curvature did not significantly correlate with PSV at CDDU (coefficient: 0.06, p=0.3). Our study confirms the lack of a significant correlation between the severity of penile curvature and CDDU parameters in men presenting with PD. These findings emerge to be relevant in terms of a more accurate management work-up for PD patients and hold insightful medicolegal implications and in the real-life setting.

Thoracic Trauma: Current Approach in Emergency Medicine.

Chest trauma is the leading cause of death in people under 40. It is estimated to cause around 140,000 deaths each year. The key aims are to reduce mortality and the impact of associated complications to expedite recovery and to restore patient's conditions. The recognition of lesions through appropriate imaging and early treatment already in the emergency department are fundamental. The majority can be managed in a non-surgical way, but especially after traumatic cardiac arrest, a surgical approach is required. One of the most important surgical procedures is the Emergency Department Thoracotomy (EDT). The aim of this review is to provide a comprehensive synthesis about the management of thoracic trauma, the surgical procedures, accepted indications, and technical details adopted during the most important surgical procedures for different thoracic trauma injuries. Literature from 1990 to 2023 was retrieved from multiple databases and reviewed. It is also important to emphasize the medico-legal implications of this type of trauma, both from the point of view of collaboration with the judicial authority and in the prevention of any litigation.

Challenges and Complications in the Management of Advanced Oropharyngeal Carcinoma: Role of Post-Mortem Diagnosis and Future Perspectives.

Oropharyngeal squamous-cell carcinoma (OPSCC) poses significant challenges in diagnosis, treatment, and management and has important medico-legal and forensic implications. In particular, the management of OPSCC and its treatment-related complications can often be challenging. In cases with advanced OPSCC, a loco-regional extension of the tumor can contribute to the destruction of oral cavity tissues, while the radiotherapy treatment can induce profound changes in tissue morphology and structure. These changes, which resemble tumor neoplasms and endovascular effects, are related to a higher risk of fatal bleeding, as reported in the case study illustrated, in which a hemorrhage occurred from a lingual artery, originating from an ulcerative, necrotic, hemorrhagic lesion on the tongue. Bleeding complications in OPSCC and prolonged radiotherapy are associated with high mortality and require comprehensive management strategies to improve survival and quality of life. Autopsy investigations, contributing to the definition of post-mortem diagnosis, can provide valuable insights into the pathogenetic mechanisms underlying bleeding and guide therapeutic decisions and preventive measures. The integration of autopsy and histopathological investigation into clinical practice should be considered as a necessary support to optimize the management of complications in advanced OPSCC patients, emphasizing the importance of a patient-centered approach and continued research.

Radial nerve injuries in humeral fractures: case series and medico-legal implications

IntroductionRadial nerve injury following humeral fracture is the most common peripheral nerve injury associated with long bone fractures. The purpose of this study is to analyse our treatment protocols and long-term outcomes of humeral fractures associated with radial nerve injury which were surgically treated at the I.R.C.C.S. Orthopaedic Institute Galeazzi (Milan, Italy). Materials and MethodsThe study was designed to evaluate retrospectively 30 patients, 15 men and 15 women, affected by humeral fracture associated with radial nerve palsy, treated at Orthopaedic Institute Galeazzi (Milan, Italy) from 1st January 2012 to 31st December 2022. Radial nerve injury was diagnosed based on the clinical evaluations of the neurological deficit. The cases were analyzed for any documented sensory impairment, wrist extensor weakness and/or finger weakness, with or without a “drop-hand” posture described in the patient's medical record at admission or throughout the hospital stay. Patients with pathological humeral shaft fractures were excluded. All patients, accounted for the study, were operated under general anaesthesia, and no peripheral nerve block was performed. ResultsThe treatment of this clinical condition represents a challenge for orthopaedic surgeons. Most patients (86.7%, 26 patients) experienced total recovery of the radial nerve function during the follow-up period, whereas only 4 patients achieved a partial nerve function recovery, with lingering weakness when extending the fingers. ConclusionsThe chronic outcomes arising from surgical treatment of the humeral fracture with related radial nerve injury can lead to impairment sequelae of greater clinical-functional significance, with possible medico-legal implications. Radial nerve injury constitutes one of the most common complications arising from humeral fracture. The course of the nerve and its close relationship with the humerus are likely to entail a high risk of injury with shaft fractures. A treatment algorithm should be recommended for the management of radial nerve injury associated with humeral shaft fracture.

Suppurative Cervicomediastinitis From the Perspective of the Head and Neck Surgeon in a Tertiary Treatment Unit.

Introduction Cervical suppurations represent an emergency pathology, with a dramatic evolution in the absence of adequate treatment. It frequently affects young people, hence the medico-legal implications of these cases. The anatomical substrate for the development of these deep cervical suppurations is represented by the cervical fascia and spaces. A distinct and extremely serious sub-chapter within diffuse cervical suppurations is necrotic cervical fasciitis, a polymicrobial infection with the most common oropharyngeal or odontogenic starting point, with rapidly progressive, destructive evolution in the deep fascial planes of the neck. Materials and method We will present a retrospective clinical study carried out on 26 cases diagnosed and treated between September 2013 and September 2018 in the ENT Clinic Department of the Bucharest University Emergency Hospital. Results Our retrospective analysis of a cohort of 26 patients in a tertiary referral center showed that deep cervical suppurations are slightly more common in men than in women. The most affected age groups were 50-59 years, followed by 20-29 years, representing a percentage of 53.84% of all cases. Also, 53.84% of the studied patients with deep cervical suppurations had a precarious and modest status. The most common clinical signs at presentation were malaise, cervical swelling, neck pain, dysphagia, fever, dysphonia, dyspnea, and cervical erythema. More than 60% of suppurations were odontogenic and 23% were caused by a traumatic element. Diabetes mellitus represents a comorbidity in 30.8% of patients, while 42.3% of patients had no personal pathological history, and thus this pathology has a lethal potential also in a patient in full health. In the study group, 46 (15%) had cervicomediastinitis, and 61.53% developed necrotizing fasciitis. One-third (34.61%) of our patients had undergone previous drainage surgery. Bacteriological examinations of the wound were with group C, D, G betahemolytic streptococcus, while 61.53% of the cultures were negative. Most patients required at least two cervicotomies. The average duration of hospitalization was 28.26 days, and the mortality rate was 23.07%; therefore, practically, one out of four cases resulted in death. In the studied group, no direct relationship can be established between the length of hospitalization and the favorable and unfavorable evolution of the patient. We propose a 10-step management protocol for the management of a cervical suppuration. Conclusion The multidisciplinary approach to these suppurations by the head and neck surgeon, the thoracic surgeon, the oromaxillofacial surgeon, anesthetist, imagist, specialist in infectious diseases, pathologist, psychologist, and so on, is the key to success in a patient who presents not only a suppuration in the throat but also a disease with systemic resonance and significant lethal potential.

Implications of artificial intelligence

The artificial intelligence (AI) revolution is underway. AI has become omnipresent in medicine, and its broad capabilities have permitted significant developments in many subspecialties including spine surgery. With AI, spine surgeons have been able to perform advanced computational analytics on vast amounts of data, allowing for solutions in each step of patient care from preoperative evaluation and planning, intraoperative execution, and postoperative evaluation. The tremendous potential of AI in medicine is clear and exciting. However, as the utility of AI in clinical practice expands, the medicolegal implications of this technology are poorly understood. In this chapter, we explore the existing technology, ethical considerations, legal challenges, and risk management strategies as it relates to AI in the field of spine surgery.

Informed consent form for platelet rich plasma injections: evidence-based and legally guide for orthopaedic surgeons

Regarding medico-legal malpractice suits, lawyers and insurers focus on informed consent documentation. Unfortunately, there is no standard protocol for obtaining informed consent for platelet-rich plasma (PRP) injections. The objective of the present study was to create a pre-designed, evidence-based informed consent form specifically for PRP injections. The current evidence on the medico-legal implications of PRP injections was accessed, as well as informed consent in general and specifically informed consent in PRP injections. Additionally, we interviewed orthopaedic surgeons and patients who had undergone PRP injections in the past year using a semi-structured approach. A legally valid and evidence-based informed consent form for PRP injections ensures rights, encouraging open communication and transparency between the patient and surgeon. Moreover, if a lawsuit arose, informed consent would be a critical document in surgeons' defence and would withstand scrutiny from lawyers and the judiciary. An evidence-based informed consent form for PRP injections was elaborated and reviewed by a legal expert to ensure adherence to legal proprieties. The final form of the informed consent for PRP injection was administered for one year and validated at our institution.

Anatomy, Etiology, Management, and Medico-Legal Implications of Botulinum-induced Blepharoptosis

Abstract: Botulinum toxin injections, a popular aesthetic treatment, have over 7.4 million beneficiaries in the U.S. Despite their safety record, these injections pose potential complications. It is essential for aesthetic practitioners to manage these complications with the least impact on the patient. Upper eyelid ptosis, though rare, is a significant side effect of botulinum toxin injections. Through our study, we have identified the etiology, anatomy, and therapeutic management of botulinum- induced blepharoptosis. Hence, the goal of this study was to identify the basic aetiology of blepharoptosis and manage this complication, as well as discuss the basis of medico-legal implications involving this popular drug. The complex medico-legal implications of botulinum toxin-induced blepharoptosis call for continuous discourse, education, and clarity on drug-use legal standards. With evolving global and Italian legislation, practitioners must ensure they meet care standards, weighing treatment benefits against potential legal and ethical outcomes. Blepharoptosis is a rare but significant complication of botulinum-type injections. Etiology and thorough anatomy are crucial for avoiding this complication and handling it with the least impact on the patient. Medico-legal implications are currently not fully established, but the basis of aesthetic treatment standards, as well as continuing medical education, will ensure correct medico-legal coverage of such complications.

Medicolegal implications of robotics in spine surgery

Robotic assistance for spine surgery has seen a resurgence in the last decade, with numerous navigation-integrated robotic systems now available for commercial use. This paper briefly reviews the historical context of robotic surgery, summarizes the current robotic spine surgery platforms, and outlines medicolegal implications and general trends of litigation for spine surgery as they relate to robotic navigation. The focus of this review is on pedicle screw instrumentation, complications, and the learning curve for robotic navigation, and how these aspects relate to medical malpractice claims.

Rate and risk factors for inpatient falls following single-level posterior lumbar fusion: A national registry study

BackgroundPosterior lumbar fusion (PLF) is frequently considered for various spinal pathologies. While many outcome metrics have been assessed, to our knowledge, there has yet to be literature specifically investigating inpatient falls (IPFs) and its risk factors. MethodsAdult patients who underwent single-level PLF were abstracted from the 2010–Q1 2022 M161Ortho PearlDiver Database. Patients who had an IPF were determined based on administrative coding. Various patient variables were extracted and variables independently associated with IPFs were assessed with multivariate logistic regression. Incidence of secondary injuries and cost incurred related to the IPF were determined. ResultsOf the 342,890 patients who underwent PLF, IPF was identified for 4,379 (1.4%). Independent predictors of an IPF in decreasing odds ratio (OR) order were those with: active psychosis (OR=3.35), active delirium (OR=2.83), history of falling (OR=2.47), commercial insurance (OR=1.59 relative to Medicare), Medicaid insurance (OR=1.47 relative to Medicare), dementia (OR=1.17), older age (OR=1.12 per decade), alcohol use disorder (O=1.11), higher comorbidity (OR=1.08 per Elixhauser comorbidity index point) (p<.05 for each).Of patients with IPF, 44 (1.0%) sustained a head injury, and 42 (1.0%) sustained a fracture. On average, those with IPF incurred greater inpatient costs compared to patients who did not ($36,865 vs. $33,921, p<.001). ConclusionIn this national sample of patients who underwent single-level PLF, postoperative IPFs were identified for 1.4% and were associated with defined patient variables. These findings have potential patient outcome, financial, and medicolegal implications and should help guide refinement of fall prevention programs.

UnTWISTing the BALS: A study of predictive accuracy of clinical scoring tools for testicular torsion identification in adults.

Testicular torsion is an uncommon but time-critical condition in EDs. If the diagnosis is missed or delayed, there are significant medicolegal and patient fertility implications. Scoring tools are advocated for use in children but have limited validation in adults. The aim of the present study was to explore the predictive accuracy of the testicular torsion scoring tools, Testicular Workup for Ischemia and Suspected Torsion (TWIST) and Boettcher Alert Score (BALS), in adult patients with a final ED diagnosis of torsion. All patients with an ED working diagnosis of testicular torsion were identified retrospectively. Data collected from digital medical records included demographics, processes of care and clinical information. The outcome of interest was the predictive performance of the scores for a confirmed diagnosis of testicular torsion as adjudicated by an urologist or a surgeon. Fifty-four patients had complete clinical data, of whom 13 had confirmed torsion. The TWIST score had a high area under the receiver operating characteristics curve (AUROC) of 0.89 (95% confidence interval [CI] = 0.78-0.999) with a score of 6-7 corresponding to a positive predictive value (PPV) of 80% (95% CI = 38-96%). The BAL score had an AUROC of 0.79 (95% CI = 0.69-0.92). PPV for a score ≥2 was 38% (95% CI = 22-56%). A high TWIST score correlates to a high likelihood of torsion and can inform surgical decision-making in the absence of US.

Challenges and innovations in the surgical treatment of advanced Dupuytren disease by percutaneous needle fasciotomy: indications, limitations, and medico-legal implications

BackgroundDupuytren disease, a chronic thickening and retraction of the palmar aponeurosis of the hands, may result in permanent and progressive flexion of one or more fingers. Percutaneous needle fasciotomy is a simple method that uses a hypodermic needle usually performed under local anaesthesia. The study aim was to report the postoperative results and complications using a percutaneous approach to treat Dupuytren contracture in a consecutive series of patients with advanced Dupuytren disease, also considering the relevant medico-legal implications.MethodsRetrospective multicentre study of all patients with Tubiana stage 3–4 Dupuytren contracture treated with percutaneous needle aponeurotomy, with no ultrasound assistance, from 2012 to 2022. Patient demographics, disease severity, treatment-related complications, and the incidence of recurrence were identified. An overview of therapeutic treatment options has accounted for 52 relevant sources spanning the 2007–2023 time period.ResultsOverall, 41.7% (N = 200) of patients were females, the mean age was 72 years (60–89), the right hand was treated in 54.2% (N = 260) of patients. The little finger was involved in 50% of the patients. The 12 months mean PED was 9°, the mean quickDASH was 8, the mean URAM 6. Minor complications were reported in 18.7% (N = 90) of patients, typically skin lacerations (83.3%) with no clinical sequelae, and no major complications were reported. Recurrence occurred in 30% (N = 144) of patients.ConclusionsPercutaneous needle fasciotomy is safe and reliable even in patients with advanced Dupuytren disease, resulting in predictably acceptable outcome with low risk of complications.

COMPLIANCE WITH THE SUSPECTED CAUDA EQUINA SYNDROME (CES) PATHWAY IN BETSI CADWALADR UNIVERSITY HEALTH BOARD (BCUHB) WEST: A RETROSPECTIVE AUDIT AGAINST NATIONAL STANDARDS

ObjectiveGuidelines published by the British Association of Spine Surgeons (BASS) and Society of British Neurological Surgeons (SBNS) recommend urgent MRI imaging and intervention in individuals suspected of having CES. The need for an evidence based protocol is driven by a lack of 24/7 MRI services and centralisation of neurosurgery to tertiary centres, compounded by CES's significant medico-legal implications. We conducted an audit to evaluate the pathway for suspected CES in BCUHB West between 2018 and 2021.MethodsA retrospective audit of patients managed for suspected CES between 01/11/2018 and 01/05/2021 was performed, using the SBNS/BASS guidelines as the standard.ResultsA total of 252 patients received an emergency MRI for suspected CES between 2018 and 2021. 99% of patients were scanned in compliance with SBNS/BASS standards. Radiological evidence of CES was found in 18% of patients. 33% of emergency scans were performed by out-of-hours services. 4% of patients had repeated scans within the same 6-month period. The majority of referrals originated from Orthopaedics surgeons (78%), or staff in the Emergency Department (8%). 92% of ambulatory patients were not admitted to hospital. During the peak of the COVID-19 pandemic, referrals increased from 2.5 to 3.5 per week.ConclusionSBNS/BASS standards were largely met, avoiding life changing disability and medico-legal consequences. The department should continue to follow SBNS/BASS guidance on the management of individuals with suspected CES. Challenges regarding the use of repeated scans should be addressed to avoid unnecessary costs. Introduction of new early recognition guidelines and Same Day Emergency Care (SDEC) has likely driven an increase in suspected CES referrals, and subsequent MRI demand. This audit should be utilised as an ongoing tool to ensure best practice continues, and to implement simple measures which may improve compliance with the pathway.

Medico-legal and bioethical controversies of the use of puberty blockers in adolescents with gender dysphoria: a comparative perspective between Italy and Spain

Background: the administration of puberty blockers to adolescents with gender dysphoria has ignited significant bioethical controversy, especially in light of recent legislative changes in the United States, Australia and several European states, especially the UK, which in March 2024 permanently banned the administration of puberty blockers to children. Italy and Spain, with their distinct legal, cultural, and medical approaches to treating gender dysphoria in minors, serve as focal points for examining these complex issues. Aims: this article aims to explore the bioethical and medico-legal implications of using puberty blockers in adolescents with gender dysphoria, focusing on the regulatory frameworks in Italy and Spain. It seeks to contribute to the international dialogue on best practices for supporting adolescents with gender dysphoria by comparing these two countries’ approaches. Discussion: in recent years in many European states there has been an important evolution in the position on hormone blockade therapy for minors with gender dysphoria, having gone from open policies on puberty blockade treatment to decidedly more restrictive positions. In Italy, the debate on the legitimacy of authorising treatment has been lively for several years, and in the last year has become even more intense due to the decisions taken by countries such as Finland, Sweden, Norway and the United Kingdom. In Spain, a landmark law on trans rights was passed in 2023, but it did not directly regulate hormone-blocking treatment in adolescents with gender dysphoria, which only made an already intense debate even more heated. Conclusion: it is essential to recognise the complexity of gender identity in adolescents and adopt an inclusive approach that considers medical, legal, ethical and social implications. The dynamic nature of the debate on the use of puberty blockers requires ongoing international dialogue. Policy analysis from Italy and Spain can inform best practice globally, promoting inclusive guidelines that prioritise adolescent welfare by addressing the complex bioethical, medico-legal and scientific issues related to the use of puberty blockers.

Surfactants and the importance of informed consent: Nurturing culturally competent care in healthcare settings.

Culturally competent healthcare improves patient satisfaction and clinical outcomes. Many drugs, dressings and implants have human or animal-derived content which may conflict with patients' religious beliefs, and may even have medicolegal implications. This cross-sectional study (anonymous web-based survey) was done to understand the informed consent process followed by paediatricians and neonatologists in India, their views regarding disclosure pertaining to the animal origin of exogenous surfactants to patients' families, and their willingness and ability to provide alternative surfactants based on parental preferences. A total of 114 neonatologists/paediatricians involved in neonatal care and using surfactants in their practice responded to the survey. Although 61(53.5%) neonatal care units stocked two or more brands of surfactant in their inventory, only 38(33.3%) units had both bovine and porcine preparations. Most (104, 91.2%) of the doctors always take parental consent before administering surfactants; but only a few (12,10.5%) said they always inform parents about its animal origin. None of the respondents offer parents a choice between bovine or porcine-origin surfactants, most (73, 64%) presuming that it would be irrelevant for the parents. However, many respondents (27, 23.7%) mentioned that they want to offer the choice to parents but are unable to do so because they do not stock both bovine and porcine preparations. Although most parents might agree to a life-saving medicine in emergency situations, this does not mean they do not want to be informed. Healthcare professionals should not have a dismissive attitude to parental belief systems. They must use the antenatal period to take the cultural/spiritual history and the necessary consent.