Medicolegal Standpoint Research Articles

Gustatory Function in Patients With Cerebellopontine Angle Masses.

To investigate the impact of cerebellopontine angle (CPA) masses on subjective and measured taste function. Retrospective cross-sectional study. Tertiary referral center. Consecutive adult patients with untreated CPA masses. Gustatory function was psychophysically measured with Taste Strips (range, 0-16) on both sides of the tongue. Subjective taste complaints were assessed using a questionnaire. Half-sided taste impairment (hemi-ageusia) was defined as side-to-side asymmetry ≥4 points with <9 points on the side of the CPA mass. We used the Koos classification for vestibular schwannomas (VS) and, in the case of facial nerve palsy, the House-Brackmann grading system. We included 135 patients (mean [standard deviation (SD)] age, 55.3 ± 14.1 yr; 62 males). The most common CPA mass was VS (77%). Overall, the measured taste function was lower on the affected compared with the healthy side of the tongue (mean score, 9.8 ± 3.3 versus 11 ± 2.9; p < 0.0001). Looking for clinically relevant one-sided taste impairment revealed 18 (13.3%) patients with hemi-ageusia, but only 4 (30.8%) of those subjectively complained of taste dysfunction. Regarding VS, Koos IV masses presented the lowest score on the affected side (mean score, 7.5 ± 3.7). Six patients presented with facial palsy. Having facial palsy did not result in a lower Taste Strips score (p = 0.23). Before any CPA mass treatment, a measurable ipsilateral decrease in gustatory function is present in many patients. Most patients do not notice this preexisting taste impairment. From a medicolegal standpoint, this warrants consideration. To avoid postoperative claims regarding taste function, a preoperative assessment may be considered.

Analysis of reasons for medical malpractice litigation due to anterior cervical discectomy and fusion

BackgroundAnterior cervical discectomy and fusions (ACDF) are among the most common cervical spine operations, with over 137,000 surgeries performed annually. Understanding reasons underlying malpractice pertaining to ACDF may inform physicians of practices to improve delivery of patient care and mitigate malpractice. The aim of our study was to analyze the causes and outcomes for lawsuits pertaining to ACDF. MethodsThe Westlaw Edge and Verdict Search databases were queried for malpractice claims utilizing the keywords “anterior cervical discectomy and fusion” and “ACDF”. Inclusion criteria was based on relevance of case grievance(s) to ACDF. Data collected included date of case hearing, plaintiff demographics, defendant specialty, verdict ruling, location of filed claim, monetary award, and sustained injuries. ResultsFifty cases were included in this study after excluding 1933 cases. Of the 50 cases, 34 (68%) resulted in a defendant outcome, 8 (16%) resulted in a plaintiff outcome, and 8 (16%) resulted in settlement. Plaintiff verdicts resulted in an average monetary payment of $9.70 million, while settlements resulted in an average payment of $2.06 million. Reasons for litigation were divided into 10 categories, most commonly improper postoperative management (20%), hardware failure (18%), intraoperative error (14%), off-label use of implants (14%), and insufficient informed consent (12%). ConclusionsMalpractice claims due to ACDF are associated with higher frequencies of plaintiff verdicts and higher monetary costs compared to other spinal surgery procedures. There does not appear to be supporting evidence that spinal cord neuromonitoring is mandatory for ACDF procedures from a medicolegal standpoint.

Cross Sectional Study to Correlate the Stature and Percutaneous Length of Ulna Bone of Pediatrics Age Group in North Karnataka State of India

BACKGROUND: Estimating stature is important for clinical, anthropological, forensic as well as medico-legal standpoint. In clinical scenarios, its significances range from estimating the BMI (body mass index) to diagnosing certain physical growth disorders and assessment of nutritional status. Height is one of the key parameters in multiple vital decision-making setting, such as: body surface area, drug dosage calculations, glomerular filtration and prediction of pulmonary function. Moreover, lack of cooperation from patient in pediatric is much common which may delay the classical method of stature estimation. Above all, height measurement is restricted to ambulatory patients only. But measurement of ulna bone overcomes all these shortcomings. The long bone, ulna is mostly subcutaneous throughout its length and easily approachable for measurement makes it the most preferable to be selected for the study. AIM: To calculate age wise stature variations among pediatric groups, to estimate percutaneous length of ulna bone, to establish a relationship between stature and percutaneous length of ulna bone, and to formulate predictive equations for calculating stature with ulnar length, respectively for each of the genders METHODS: The study was conducted at the pediatric ward of a medical college in North Karnataka from August 1,2022 to December 31, 2022. Sample size for proportion was calculated to be 96, taking 33% as P (Pilot study) and at 5% absolute precision at 95% confidence level. All steps and precautions were followed appropriately as per guidelines published by World Health Organization. Length of ulna bone was measured using a measuring tape (0-152cm/60 inches) with rounded ends, from the tip of the olecranon process to the tip of the styloid process of ulna keeping elbow joint flexed and palm spread over opposite shoulder. Measurements of length of both the right and left ulna were taken separately for calculation. Both the stature and the length of ulna were measured in centimeters. Means of age, length of ulna and body height/length were analyzed amongst both the genders for each age group. Data analysis would be done using Statistical Package for the Social Sciences; SPSS version 23; p≤0.05 would be considered statistically significant. RESULTS: In the study, relationship between stature and percutaneous length of ulna bone were analyzed and predictive equations for calculating stature with ulnar length, respectively for each of the genders were formulated as: For males, length or height = 6.545455 × (mean ulnar length of both the arms) ±0.3cm. For females, length or height = 6.540540 × (mean ulnar length of both the arms) ±0.3cm. CONCLUSION: The study suggests that there is a linear correlation between stature and ulna bone length in pediatric age groups. The derived equation can be used to estimate the stature of pediatric age group, specific to the gender. Similarly, length of ulna bone may be estimated if the stature is known. It will contribute greatly towards anthropometry and its widespread applications in clinics and forensics.

AUTHOR REPLY

Testicular torsion (TT) sometimes involves difficult decision-making for urologists/surgeons from the medicolegal standpoint. From the perspective of the patient and their parents, they would prefer that the testicles be preserved, even if reoperation (e.g., resection of a necrotic testicle) may be necessary. Hence, this study aimed to examine the preservation of grossly ischemic testicles beyond the “golden time”.

Sugammadex Use for Reversal in Nonobstetric Surgery During Pregnancy: A Reexamination of the Evidence.

Sugammadex Use for Reversal in Nonobstetric Surgery During Pregnancy: A Reexamination of the Evidence.

Trauma Forensics in Blunt and Sharp Force Injuries.

Trauma forensics is the concept of examining trauma from a medicolegal standpoint in a given jurisdiction. Blunt and sharp force traumas are classified based on the different mechanisms of causation, which have a medicolegal significance. Adopting a standard approach to the medical evaluation of such injuries in patients would serve both the purposes of rendering appropriate treatment and the documentation and preservation of medical evidence. However, most trauma cases are seen by medical practitioners with very limited forensic knowledge and skills, and they are still expected to meet the needs of the court or the judicial mechanism in subsequent legal proceedings. Therefore, some measures, including 10 practical considerations, which are applicable in attending to blunt and sharp force traumas, would limit the risk a clinician faces in the crossfire of medicine and law.

Collateral Effect of the Pandemic on Ultrasound.

We have been following publications on ultrasound of the lung in patients with COVID 19 with great interest [1] [2] [3]. We also know all the precautionary measures for an ultrasound examination of a patient who has tested positive for SARS-CoV-2. However, this pandemic seems to have an even greater impact on the ultrasound community. As not all patients we see are tested for SARS-CoV-2, we are confronted with additional organizational measures and intensified hygiene protocols in our clinical routine outside the isolation ward. On a daily basis we are reminded that our knowledge of SARS-CoV-2 is still incomplete and that the benefit of some hygienic measures is under debate. Still, the latter are advised or at least recommended from a medicolegal standpoint. In interesting surveys conducted before the SARS-CoV-2 pandemic, the ultrasound decontamination procedures of the ultrasound community were assessed in questionnaires [4] [5]. Regarding surface or endo-cavity ultrasound or interventional procedures, the practice for decontamination was inhomogeneous. Long before this pandemic, some ultrasound societies (e. g. EFSUMB, AIUM) released recommendations for cleaning and disinfecting probes. Nevertheless, we can assume that there were many “different interpretations” of good practice. So maybe this pandemic will lead to a long-term change and improvement of our practice for probe decontamination.

Pediatric penile surgery by a nurse practitioner in the operating room

With the growing shortage of pediatric urological surgeons, it was our aim to streamline our system to get patients with less complex penile procedures performed in a timely manner. To do this, an advanced practice provider (APP) was trained to perform minor penile procedures in children in the operating room(OR). The goal of our study was to show that with proper training an APP could safely perform a circumcision in the OR. After approval of the study center's credentialing committee, a NP was trained to perform revisions and initial circumcisions in children in the OR. The process involved: (1) observation, (2) first assisting and (3) performing the procedure with direct, and later in-direct, supervision. The first 100 cases were evaluated for surgical complications, post-operative complications and return rates to the OR. 100 independent cases were completed with 90 having only in-direct supervision. There were no operative complications, nor any documented emergency room or urgent care visits in the immediate post-operative period. There were no early returns to the OR and only 1 scheduled follow-up procedure for a penile skin bridge. It was demonstrated that with proper training a NP can safely perform minor penile procedures in the OR. This allows us to free up our pediatric urology physicians to see and operate on more complex pediatric urology problems. In addition, it allows those with minor penile issues to be cared for more expeditiously. A concern related to training NPs to do circumcisions could be the loss of control by urologists. In this situation, the attending physician is ultimately responsible from a medico-legal standpoint. That would not be true if the NP was practicing independently. With a shortage of urologists, this significantly expands the ability to care for our patient population. In additional, attending surgeons will have a greater freedom to perform major procedures. A limitation of the study was that a patient satisfaction survey was not obtained to see if there were concerns over a APP doing their circumcision. Personal feedback on 30 of the patients that did not return for the follow-up visit was not obtained. The authors of the study are primary providers of pediatric urology care in the study region, thus any individual with concerns would have been referred. It was demonstrated that a well-trained APP can safely perform minor penile procedures independently in the OR with indirect supervision.

Mandibular Implant Overdentures: Treatment and Medico-Legal Considerations.

The concept of a two-implant overdenture as the minimum standard of care or first choice treatment for the edentulous mandible was first proposed in 2002 and has since been backed by an overwhelming body of evidence supporting greater patient satisfaction and improved quality of life. This article examines the implant overdenture concept and its various options and discusses best practice from both the patient's and a medico-legal standpoint.

Patient-Reported Use of Personalized Video Recordings to Improve Neurosurgical Patient-Provider Communication.

Background: Providing patients with a video recording of their visit with a medical professional is a common-sense method for improving patient-provider communication.Objective: To describe the patient and provider experiences to video recording clinical medical encounters and providing the patient with a copy of the video for informational purposes.Methods: Since 2009, over 2,800 patients of eight different neurosurgeons chose to be video recorded during their encounter with the doctor and were provided access to the recording to watch over again as a way to recall what the doctor had said. The video system was set up as a handheld video camera, and video files were downloaded and made accessible to patients via a secure Internet patient portal. Between 2012 and 2014, patients who participated were surveyed regarding their use of the video and what was recorded on the video. The experience of the providers from a clinical and medico-legal standpoint was also reviewed.Results: Three hundred and thirty-three responses to the survey were received (39.2% response rate). More than half of patients (N=333; 56.2%) watched their video more than once, and over two-thirds (N=333; 68.6%) shared their video with a family member, friend, or another physician. Patients self-reported improved memory after watching their videos (N=299; 73.6% could remember more) and 50.2% responded that having the video made them feel more “at ease” with their medical problem (N=299). Overall, 88.0% of respondents indicated that their video had been helpful to them, and 98.5% would recommend having future visits video recorded. No patient made a comment that the video was intrusive or had prevented them from being open with their doctor. Finally, in the high-risk specialty of neurosurgery, none of the 2,807 patients who have been recorded since 2009 have used a video in a medico-legal action.Conclusions: Patient responses to the recording system and having a copy of their video were very positive. Most respondents indicated that they had improved memory as well as decreased anxiety about their neurosurgical problem. There have been no legal challenges to date from giving patients access to the video recording. Our results indicate that the benefits to patients for expanding the use of video in medicine may outweigh perceived risks to providers.

Translating intentions to prescriptions: Mind the gap!

Translating intentions to prescriptions: Mind the gap!

EComment. Daily routine chest radiographs after pulmonary surgery

We read with great interest the paper by Reeb et al. [1] regarding the utility of daily routine (DR) chest radiographs following pulmonary surgery. They concluded that the on-demand (OD) strategy of obtaining chest X-rays only when clinically indicated, led to equivalent outcomes while reducing radiation exposure and cost of care. Rather than completely do away with DR chest X-rays, it would be interesting to try and identify subgroups of patients who may benefit from this strategy. Earlier studies suggested that pulmonary or unstable cardiac patients, and patients with pulmonary artery catheters, needed daily X-ray monitoring. The American College of Radiology (ACR) previously recommended DR chest radiographs for patients with acute cardiopulmonary problems and those on mechanical ventilation. They have since revised the ACR Appropriateness Criteria in 2011, to favour the more selective OD approach [2]. Cerfolio et al. have found that DR chest X-rays are warranted in post-thoracotomy patients who are hypoxic [1]. In this sub-group, 79% of patients had a radiological finding that influenced their care. Oba et al. [3] however, were not able to identify any sub-population of critically ill patients, who would benefit from DR chest X-rays. The OD strategy has slowly gained acceptance in clinical practice. Graat et al. [4] reported in 2006, that although intensivists doubted the value of DR chest radiography, they were still reluctant to change their practice. More recently, the RadioDay study [5] found that two-thirds of French intensive care units had moved over to ordering chest X-rays on an OD basis. The hesitation to abandon the traditional approach may be related to the comfort level of the intensive care team, and the objectivity of a chest X-ray from a clinical and medico-legal standpoint. Another caveat is, that patients will have to be more closely monitored for changes in their cardiopulmonary status for the OD approach to be successful. Pending the results of further studies, the most efficient plan for utilization of resources may have to be tailored to each individual patient in order to achieve the best outcome. Conflict of interest: none declared.

Chirurgia dell’ottavo inferiore e lesioni del nervo linguale. Aspetti clinici e medico-legali

Objectives This paper examines possible complications and nervous lesions associated with third mandibular molar surgery focusing on lingual nerve injuries. Materials and Methods On the basis of an extensive literature review and of anatomical and physiological considerations, the authors show that third mandibular molar surgery may cause reversible and irreversible nervous lesions. From a medico-legal perspective an accurate distinction between complications and technical errors is difficult. Results and conclusions In spite of a proper implementation, there is the risk of complications in oral surgery. A very small percentage of nervous lesions is due to anaesthetic injections. This accident is therefore considered rare, even though possible. Several authors assessed frequency and etiology of lesions due to mandibular third molar surgery, but contrasting findings emerged. Different opinions exist about the possibility of a partial or total recovery. Being the exact distinction between complication and technical mistake impossible, from a medico-legal standpoint the estimate of a damage may turn out to be complicated, so that compensation may be required.

Interpreter Services in An Inner City Teaching Hospital: A 6-Year Experience

Being able to communicate effectively with patients is essential not only from a medicolegal standpoint but more importantly from clinical governance perspectives. Issues such as informed consent and patient choice within the NHS are currently being highlighted; for these to be available to patients, their language requirements are paramount. An audit was performed by the Linkworkers office at the Central Manchester & Manchester Children's Hospital NHS (CMMC) Trust on the total number of attendances and refusals per language in the period 1998-2003. In the CMMC Trust, Urdu/Punjabi, Bengali, Cantonese, Somali, Arabic and French represent the majority of the workload, comprising almost 80% of cases in 2003. In the same year, an increase in demand for languages of Eastern European countries became evident. Finding interpreters for these languages even via agencies can be extremely difficult. If the current trend continues, requirement for these services will increase exponentially. For this demand to be met adequately these issues must be kept at the forefront of NHS planning.

Tips for Medical Record Documentation and Maintenance

Whether your practice uses electronic health records or paper, these documentation rules are applicable. Good documentation reflects quality care and is crucial from a medicolegal standpoint. Review your medical records to see how compliant you are with these basic rules. Remember, if it isn’t documented or can’t be read, it didn’t happen!

Seen and Agree: Are You Compliant With Teaching Physician Guidelines?

Seen and Agree: Are You Compliant With Teaching Physician Guidelines?

Taste Disorders after Tonsillectomy: Case Report and Literature Review

The authors describe a case of dysgeusia that occurred during the recovery period after a tonsillectomy. The cause was thought to be a lesion to the lingual branch of the glossopharyngeal nerve because of the location of the symptoms at the posterior region of the buccal cavity and because of the raised electrogustometric thresholds in the posterior region of one half of the tongue. Clarification of this type of case was made by a review of the literature from 1966 to June 2004, carried out with the aid of Medline. From a medicolegal standpoint, it is important to inform the patient of the risk of dysgeusia after tonsillectomy, especially if that patient has a profession in which taste plays an essential role.

La RM nelle sequele dei traumi cranici

Given the higher sensitivity of MRI and the recent advances in faster imaging techniques the purpose of the study was to obtain MRI findings in 70 patients who had suffered from a head injury with transient consciousness loss or prolonged coma at least 24 months before entering the study. Multiplanar MRI offers invaluable advantages in the identification of the precise location of the sequelae of cranial traumas. In case of hemorrhagic lesions, the information capacity of CT progressively diminishes in relation to the absorption of the edema and bleeding, whereas MRI increases its sensitivity due to the paramagnetic properties of hemoglobin by-products. MRI allows the identification of a larger amount of small lesions, particularly those located at critical sites, as corpus callosum, temporal and frontal tips cortical surface. Using Fluid Attenuated Inversion Recovery (FLAIR) pulse sequences, a better delineation of cortical and subcortical lesions is permitted, with remarkable improvement of sensitivity when compared with conventional Spin-Echo images. Finally, adopting MRI has important implications from a medico-legal standpoint.

PHYSICIAN IMPAIRMENT BY SUBSTANCE ABUSE

Physician impairment by substance abuse represents a significant challenge to physicians, patients, and society as a whole. Although data is sparse, the prevalence of alcohol and illicit drug abuse among physicians is probably similar to that of the general population, while abuse of prescription drugs may be more prevalent. From a medicolegal standpoint, these issues are managed mostly at the state level and substance abuse is of increasing interest to credentialling organizations such as hospitals and managed care organizations. A variety of concrete steps can be taken to identify physicians with substance abuse problems and treatment approaches have been designed specifically for impaired physicians. With improved attention to the problem of physician impairment by substance abuse, the well-being of both physicians and their patients can be enhanced.

The search for the elusive electronic medical record system--medical liability, the missing factor.

Over the past few years, the traditional paper-based medical record system has come under close scrutiny by every participant in the healthcare industry. Some groups, especially federal agencies such as Medicare and Medicaid, HMOs, and other third party payors, have begun to demand changes in medical record documentation, and have become very assertive as to what goals and objectives will be met. In contrast, the medical liability insurance industry has remained almost invisible during this period of transition. At a recent electronic medical records (EMR) conference participants attending a software development workshop were asked if they had their systems reviewed from a medicolegal standpoint by a malpractice insurance carrier. In response to this inquiry, not one software vendor raised their hand to indicate this had been accomplished, or was even contemplated. In the author's opinion, the key missing factor in the current quest for a paperless medical office system rests in the domain of those who represent the medical liability industry. All of these gate-keepers of medical loss and risk prevention will eventually be called upon, either by choice or necessity, to validate every working EMR system that is used in medical practices in the future. This article will explore the best information published from this currently silent sector of the industry, and proposes an active involvement by the medical liability industry in the current EMR design and development processes taking place. In addition, there are 10 minimum EMR design criteria contained in this article that are recommended for implementation based upon 16 years of medical malpractice experience and loss prevention input.