Adjudication Process Research Articles

Child Sexual Abuse by Fathers in India: Exploring the Layers of ‘Honour’ in Trials

ABSTRACT Feminist scholarship has devoted significant time and space to critiquing court judgments that make patriarchal-normative assumptions about consent, resistance to sex, ‘provocation’ of dress, habituation to sex, etc. in rape cases. Hence, this paper asks whether rape and sexual abuse trials would be devoid of patriarchy were it not for these routinely repeated patriarchal-normative scripts. It does this by looking at cases where allegations of consent to sex, blame for initiating sex, previous sexual encounter, clothing, and so on are not raised. To that end, this paper looks at Indian trial court judgments of child sexual abuse in which the child is a female and the accused is her father/step-father (CSAF). Judgments on CSAF, nevertheless, raise questions about sexual history, what establishes credibility, character, hostility, easy acquittal, etc. However, it would be reductive to view these questions as a simple reiteration of what emerges in most other rape cases. This is because what most significantly unfolds in CSAF cases are points of divergence from other cases of child sexual abuse and sexual abuse generally. These divergences lead to new questions: Whose sexual history is raked up? Whose character is assessed? How is rape disbelieved when consent becomes immaterial? What peculiarities lead to an acquittal? These divergences appear because the survivor of sexual abuse in all these cases was not simply a female, but a daughter. Interpreting these divergences, this paper articulates that concerns of ‘honour’ run through the process of legal adjudication in CSAF cases. The honour concerned is not only of the child who suffers abuse, but also her mother’s; the honour concerned is not only a person’s, but also the nation’s.

Compensation and Pension Exams for Military Sexual Trauma-Related Posttraumatic Stress Disorder: Examiner Perspectives, Clinical Impacts on Veterans, and Strategies.

It is estimated that in one in three women veterans experience military sexual trauma (MST), which is strongly associated with posttraumatic stress disorder (PTSD). A 2018 report indicated the Veterans Benefits Administration (VBA) processed approximately 12,000 disability claims annually for PTSD related to MST, most of which are filed by women. Part of the VBA adjudication process involves reviewing information from a Compensation and Pension (C&P) exam, a forensic diagnostic evaluation that helps determine the relationship among military service, diagnoses, and current psychosocial functioning. The quality and outcome of these exams may affect veteran well-being and use of Veterans Health Administration (VHA) mental health care, but no work has looked at examiner perspectives of MST C&P exams and their potential clinical impacts on veteran claimants. Thirteen clinicians ("examiners") who conduct MST C&P exams through VHA were interviewed. Data were analyzed using rapid qualitative methods. Examiners described MST exams as more clinically and diagnostically complex than non-MST PTSD exams. Examiners noted that assessing "markers" of MST (indication that MST occurred) could make veterans feel disbelieved; others raised concerns related to malingered PTSD symptoms. Examiners identified unique challenges for veterans who underreport MST (e.g., men and lesbian, gay, bisexual, transgender, and queer [LGBTQ+] veterans), and saw evaluations as a conduit to psychotherapy referrals and utilization of VHA mental health care. Last, examiners used strategies to convey respect and minimize retraumatization, including a standardized process and validating the difficulty of the process. Examiners' responses offer insight into a process entered by thousands of veterans annually with PTSD. Strengthening the MST C&P process is a unique opportunity to enhance trust in the VBA claims process and increase likelihood of using VHA mental health care, especially for women veterans.

The dynamics of Islamic marital jurisprudence in Islamic courts: the experience of the Kwara state and Zanzibar

Zanzibar is an island located in East Africa and part of the United Republic of Tanzania. In contrast, Kwara State is one of the states of the Federal Republic of Nigeria in the West Africa sub-region. Both regions have similar colonial histories and post-colonial experiences. Islamic Jurisprudence has undergone many reforms since the post-colonial era in Zanzibar Island of Tanzania and Kwara State of Nigeria. Islamic Jurisprudence is used in the adjudication process in Islamic religious courts in these two regions of Africa with a sizeable Muslim population. These courts essentially adjudicate Muslim personal matters, such as marriage, divorce, inheritance, wills, and endowment. The official jurisprudence of the people Zanzibar-Tanzania is Shafi’i jurisprudence. For the people of Kwara State of Nigeria, Maliki jurisprudence is recognized. Marriage is considered part of Muslim identity; therefore, applicable jurisprudence is necessary for a fair hearing on Muslim personal matters. The Muslim judges (qadis) play a laudable role in the justice system under Islamic Jurisprudence. This paper uses doctrinal, case law and empirical approaches for the discourse.

Targeted multidomain intervention for complex mTBI: protocol for a multisite randomized controlled trial in military-age civilians.

Mild traumatic brain injury (mTBI) affects ~18,000 military personnel each year, and although most will recover in 3-4 weeks, many experience persisting symptoms and impairment lasting months or longer. Current standard of care for U.S. military personnel with complex mTBI involves initial (<48 h) prescribed rest, followed by behavioral (e.g., physical activity, sleep regulation, stress reduction, hydration, nutrition), and symptom-guided management. There is growing agreement that mTBI involves different clinical profiles or subtypes that require a comprehensive multidomain evaluation and adjudication process, as well as a targeted approach to treatment. However, there is a lack of research examining the effectiveness of this approach to assessing and treating mTBI. This multisite randomized controlled trial (RCT) will determine the effectiveness of a targeted multidomain (T-MD) intervention (anxiety/mood, cognitive, migraine, ocular, vestibular; and sleep, autonomic) compared to usual care (behavioral management) in military-aged civilians with complex mTBI. This study employs a single-blinded, two-group repeated measures design. The RCT will enroll up to 250 military-aged civilians (18-49 yrs) with a diagnosed complex mTBI within 8 days to 6 months of injury from two concussion specialty clinics. The two study arms are a T-MD intervention and a usual care, behavioral management control group. All participants will complete a comprehensive, multidomain clinical evaluation at their first clinical visit. Information gathered from this evaluation will be used to adjudicate mTBI clinical profiles. Participants will then be randomized to either the 4-week T-MD or control arm. The T-MD group will receive targeted interventions that correspond to the patient's clinical profile (s) and the control group will receive behavioral management strategies. Primary outcomes for this study are changes from enrollment to post-intervention on the Neurobehavioral Symptom Inventory (NSI), Patient Global Impression of Change (PGIC), and functional near-infrared spectroscopy (fNIRS). Time to return to activity (RTA), and healthcare utilization costs will also be assessed. Study findings may inform a more effective approach to treat complex mTBI in military personnel and civilians, reduce morbidity, and accelerate safe return-to-duty/activity. The study is approved by the University of Pittsburgh Institutional Review board and registered at clinicaltrials.gov. Dissemination plans include peer-reviewed publications and presentations at professional meetings. www.clinicaltrials.gov, identifier: NCT04549532.

Overcoming Global Issues on Gender-Biased in Adjudication Process: The Role of Companions for Rape Victims

Overcoming Global Issues on Gender-Biased in Adjudication Process: The Role of Companions for Rape Victims

Necessity of Online Dispute Resolution (ODR) in Family Matters and Legal Implementation of Online Court System

Technology is transforming Alternative Dispute Resolution (ADR). Defying long-held assumptions that developing empathy, broadening understanding, and coming up with solutions are only possible in person, effective approaches for assisting in the resolution of the growing number of arguments that have developed online have emerged. Technology has become the "fourth party" in settling disputes, thanks to the developing field of Online Dispute Resolution (ODR), which includes the use of technology and computer-mediated communication (CMC) in negotiation, mediation, arbitration, and other dispute resolution processes. ODR is being used by courts in numerous countries for family-related matters. The expectations and duties that are placed on the ODR community and its practitioners are examined in this research, which uses a qualitative technique. In particular, the study emphasizes the importance of ODR in resolving family disputes, critical moral standards for the technology used in ODR, and critical moral standards for the technology used in ODR, and makes suggestions for how Pakistan's judiciary can enhance its current online court model to facilitate greater access to justice and speed up the entire adjudication process. The paper also offers ideas on how the judicial system might continue to disseminate information with integrity, quality, and promptness.

Major cardiovascular events after COVID-19, event rates post-vaccination, antiviral or anti-inflammatory therapy, and temporal trends: Rationale and methodology of the CORONA-VTE-Network study

BackgroundCoronavirus disease 2019 (COVID-19) is associated with excess risk of cardiovascular and thrombotic events in the early post-infection period and during convalescence. Despite the progress in our understanding of cardiovascular complications, uncertainty persists with respect to more recent event rates, temporal trends, association between vaccination status and outcomes, and findings within vulnerable subgroups such as older adults (aged 65 years or older), or those undergoing hemodialysis. Sex-informed findings, including results among pregnant and breastfeeding women, as well as adjusted comparisons between male and female adults are similarly understudied. MethodsAdult patients, aged ≥18 years, with polymerase chain reaction-confirmed COVID-19 who received inpatient or outpatient care at the participating centers of the registry are eligible for inclusion. A total of 10,000 patients have been included in this multicenter study, with Brigham and Women's Hospital (Boston, MA) serving as the coordinating center. Other sites include Beth Israel Deaconess Medical Center, Anne Arundel Medical Center, University of Virginia Medical Center, University of Colorado Health System, and Thomas Jefferson University Health System. Data elements will be ascertained manually for accuracy. The two main outcomes are 1) a composite of venous or arterial thrombotic events, and 2) a composite of major cardiovascular events, defined as venous or arterial thrombosis, myocarditis or heart failure with inpatient treatment, new atrial fibrillation/flutter, or cardiovascular death. Clinical outcomes are adjudicated by independent physicians. Vaccination status and time of inclusion in the study will be ascertained for subgroup-specific analyses. Outcomes are pre-specified to be reported separately for hospitalized patients versus those who were initially receiving outpatient care. Outcomes will be reported at 30-day and 90-day follow-up. Data cleaning at the sites and the data coordinating center and outcomes adjudication process are in-progress. ConclusionsThe CORONA-VTE-Network study will share contemporary information related to rates of cardiovascular and thrombotic events in patients with COVID-19 overall, as well as within key subgroups, including by time of inclusion, vaccination status, patients undergoing hemodialysis, the elderly, and sex-informed analyses such as comparison of women and men, or among pregnant and breastfeeding women.

The US Immigration Courts, Dumping Ground for the Nation’s Systemic Immigration Failures: The Causes, Composition, and Politically Difficult Solutions to the Court Backlog

The US immigration court system seeks to “fairly, expeditiously, and uniformly administer and interpret US immigration laws” (DOJ 2022a). It represents the first exposure of many immigrants to due process and the rule of law in the United States, and occupies an integral role in the larger US immigration system. Yet it labors under a massive backlog of pending cases that undermines its core goals and objectives. The backlog reached 1.87 million cases in the first quarter of FY 2023 (Straut-Eppsteiner 2023, 6). This paper attributes the backlog to systemic failures in the broader immigration system that negatively affect the immigration courts, such as: Visa backlogs, United States Citizen and Immigration Services (USCIS) application processing delays, and other bottlenecks in legal immigration processes. The immense disparity in funding between the court system and the Department of Homeland Security (DHS) agencies that feed cases into the courts. The failure of Congress to pass broad immigration reform legislation that could ease pressure on the enforcement and court systems. The lack of standard judicial authorities vested in Immigration Judges (IJs), limiting their ability to close cases; pressure parties to “settle” cases; and manage their dockets. The absence of a statute of limitations for civil immigration offenses. Past DHS failures to establish and adhere to enforcement priorities and to exercise prosecutorial discretion (PD) throughout the removal adjudication process, including in initial decisions to prosecute. The location of the Executive Office for Immigration Review (EOIR), which oversees US immigration courts, within the nation’s preeminent law enforcement agency, the Department of Justice (DOJ). The misconception of many policymakers that the court system should primarily serve as an adjunct to DHS. A past record of temporary judge reassignments and government shutdowns. The paper supports a well-resourced and independent immigration court system devoted to producing the right decisions under the law. Following a short introduction, a long section on “Causes and Solutions to the Backlog” examines the multi-faceted causes of the backlog, and offers an integrated, wide-ranging set of recommendations to reverse and ultimately eliminate the backlog. The “Conclusion” summarizes the paper’s topline findings and policy proposals.

Prevalence of concealed arrhythmogenic substrate for sudden cardiac arrest in the general population

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): US National Heart Lung and Blood institute National Institute of Health. Background Individuals who present with SCA as the first manifestation of heart disease (Concealed Substrate) present the greatest challenge for clinical risk stratification but population-based information in the current era is lacking. We hypothesized that improved awareness and access to health care has resulted in a reduction in prevalence of Concealed Substrate. Purpose We compared the overall prevalence, secular trends and SCA etiologies of Concealed Substrate in two geographically distinct US populations. Methods Consecutive cases of SCA were ascertained prospectively from 2 large ongoing US studies, the Population Cohort A (PopulationCohortA, 2002-2018) and Population Cohort B (PopulationCohortB, 2015-2022), total population 1.85 million residents. All out-of-hospital SCA events attended by emergency medical services were determined following an established multi-source ascertainment and adjudication process, and detailed lifetime clinical record evaluation conducted for each individual. This included the comprehensive electronic health record, evaluation of SCA survivors as well as all available autopsy information. Concealed Substrate cases were defined as SCA with no prior heart disease diagnosis. Results From a total of 5708 SCA cases (age 66.5 ± 18.2, female 35%), n=3390 (age 64.3 ± 18.8, female 34%) were identified in PopulationCohortA and n=2318 (age 71.6 ± 15.7, female 36%) in PopulationCohortB. In PopulationCohortA, prevalence of Concealed Substrate was 39% (n=1282, age 58.6 ± 21.7, 32% female) and decreased modestly over time (Figure; 37% in 2002-06 vs. to 33% in 2014-18; p=0.001). In PopulationCohortB, overall prevalence of Concealed Substrate was 41% (n=949, age 68.3 ± 17.6, 33% female) and did not change significantly over time (Figure; 2015-2022; p=0.06). Etiology of SCA was determined in a subgroup of overall cases (n=3210, 56%) of which n=2727 (85%) were ischemic SCA and n=483 (15%) non-ischemic SCA. Non-ischemic SCA was more commonly identified in Concealed Substrate (29% vs. 11%; p&amp;lt;0001) and ischemic SCA was more common in Revealed Substrate (89% vs. 72%; p&amp;lt;0.0001). Conclusion There was a modest reduction in prevalence over time, 33-41% of individuals continued to present with Concealed Substrate, with higher likelihood of non-ischemic SCA. These findings suggest that widely available and inexpensive tests such as the 12-lead ECG warrant further evaluation as a pre-screening method in the general population.

Efficacy of Adjudication Process of Corporate Insolvency Resolution Process (CIRP): Law and Economics of National Company Law Tribunal (NCLT)

Abstract National Company Law Tribunals (NCLTs) form the backbone of the institutional setup of the corporate law mechanism. The tribunals though were initially given a minimal role in the judicial procedure of the corporate world and were seen with scepticism, their significance could not be ignored for long. With the increase in insolvency disputes, the NCLTs were even given the jurisdiction to handle the cases regarding the Insolvency and Bankruptcy Code (IBC) and Corporate Insolvency Resolution Process (CIRP) . However, the efficiency of these tribunals has to be inspected with respect to CIRP cases for knowing the clear picture. In this paper, an economic analysis of the working of the NCLT Ahmedabad is undertaken to get a better understanding of the efficiency of the NCLTs in general. The study relies on qualitative tools such as interviewers conducted by relevant stakeholders and observing NCLT court proceedings to capture the measurement reality of NCLT efficiency. The study also relies on descriptive statistics of time taken and recovery to measure the efficacy of NCLT.

Judiciary Problems in Mature Democratic Countries: American and French Perspectives

&lt;p&gt;&lt;em&gt;Even when all other safeguards fail, a judiciary of unquestionable integrity is the cornerstone institution necessary for guaranteeing adherence to democracy and the rule of law. It protects the public from any violations of their legal rights and freedoms. This observation applies to both global analyses of the judicial system and rule of law process in America and France, in particular. The judiciary and legal adjudication process were viewed and examined as a great bastion of the rule of law throughout the United States of America and France as one of the great countries that are characterized as mature democracies in this paper, which relied on the qualitative method of data collection.&lt;/em&gt;&lt;/p&gt;

MP-453090-5 SUDDEN CARDIAC ARREST AS THE FIRST MANIFESTATION OF HEART DISEASE IN THE GENERAL POPULATION

The subgroup of individuals who present with sudden cardiac arrest (SCA) as the first manifestation of heart disease (FM-SCA) present the greatest challenge to effective clinical risk stratification, but population-based data in the current era is lacking. We hypothesized that improved awareness and access to health care has resulted in a reduction in prevalence of FM-SCA. We compared the prevalence secular trends of FM-SCA in two geographically distinct US populations and evaluated distinguishing characteristics. Consecutive cases of SCA were ascertained prospectively from 2 large ongoing US studies, the Oregon Sudden Unexpected Death Study (OreSUDS, Portland OR, USA, 2002-2018) and Prediction of Sudden Death in Multi-ethnic Communities (PRESTO, Ventura CA, USA, 2015-2022), total population 1.85 million residents. All out-of-hospital SCA events attended by emergency medical services were determined following an established multi-source ascertainment and adjudication process, and a detailed review of the comprehensive lifetime clinical records was conducted for each individual. Both SCA survivors and non-survivors were included. FM-SCA cases were defined as SCA with no prior heart disease diagnosis. A multi-variable model using combined data from both cohorts was used to identify distinguishing characteristics of FM-SCA vs. other SCA. A total of 3390 SCA cases (age 64.3 ± 18.8, female 34%) were identified in OreSUDS and n=2318 (age 71.6 ± 15.7, female 36%) in PRESTO. In OreSUDS, prevalence of FM-SCA was 39% (n=1282, age 58.6 ± 21.7, 32% female) and decreased modestly over time (Figure; 37% in 2002-06 to 33% in 2014-18; p=0.001 for trend). In PRESTO, overall prevalence of FM-SCA was 41% (n=949, age 68.3 ± 17.6, 33% female) and did not change significantly over time (Figure; 2015-2022; p=0.06 for trend). In multivariate comparisons of FM-SCA vs. other SCA performed in the subset of individuals with healthcare visits, younger age, male sex and lower rates of diabetes, hypertension, seizure disorder, chronic obstructive pulmonary disease and chronic renal insufficiency were associated with FM-SCA (p <0.0001). There was a modest reduction in prevalence over time, but 33-41% of individuals continued to present with FM-SCA and were distinguished by younger age, male sex and lower rates of co-morbid conditions. These findings suggest the need to develop and investigate user-friendly and cost-effective pre-screening methods to reduce FM-SCA in the general population.

Antimicrobial use in pediatric oncology and hematology in Germany and Austria, 2020/2021: a cross-sectional, multi-center point-prevalence study with a multi-step qualitative adjudication process.

Due to the high risk of severe infection among pediatric hematology and oncology patients, antimicrobial use is particularly high. With our study, we quantitatively and qualitatively evaluated, based on institutional standards and national guidelines, antimicrobial usage by employing a point-prevalence survey with a multi-step, expert panel approach. We analyzed reasons for inappropriate antimicrobial usage. This cross-sectional study was conducted at 30 pediatric hematology and oncology centers in 2020 and 2021. Centers affiliated to the German Society for Pediatric Oncology and Hematology were invited to join, and an existing institutional standard was a prerequisite to participate. We included hematologic/oncologic inpatients under 19 years old, who had a systemic antimicrobial treatment on the day of the point prevalence survey. In addition to a one-day, point-prevalence survey, external experts individually assessed the appropriateness of each therapy. This step was followed by an expert panel adjudication based upon the participating centers' institutional standards, as well as upon national guidelines. We analyzed antimicrobial prevalence rate, along with the rate of appropriate, inappropriate, and indeterminate antimicrobial therapies with regard to institutional and national guidelines. We compared the results of academic and non-academic centers, and performed a multinomial logistic regression using center- and patient-related data to identify variables that predict inappropriate therapy. At the time of the study, a total of 342 patients were hospitalized at 30 hospitals, of whom 320 were included for the calculation of the antimicrobial prevalence rate. The overall antimicrobial prevalence rate was 44.4% (142/320; range 11.1-78.6%) with a median antimicrobial prevalence rate per center of 44.5% (95% confidence interval [CI] 35.9-49.9). Antimicrobial prevalence rate was significantly higher (p<0.001) at academic centers (median 50.0%; 95% CI 41.2-55.2) compared to non-academic centers (median 20.0%; 95% CI 11.0-32.4). After expert panel adjudication, 33.8% (48/142) of all therapies were labelled inappropriate based upon institutional standards, with a higher rate (47.9% [68/142]) when national guidelines were taken into consideration. The most frequent reasons for inappropriate therapy were incorrect dosage (26.2% [37/141]) and (de-)escalation/spectrum-related errors (20.6% [29/141]). Multinomial, logistic regression yielded the number of antimicrobial drugs (odds ratio, OR, 3.13, 95% CI 1.76-5.54, p<0.001), the diagnosis febrile neutropenia (OR 0.18, 95% CI 0.06-0.51, p=0.0015), and an existing pediatric antimicrobial stewardship program (OR 0.35, 95% CI 0.15-0.84, p=0.019) as predictors of inappropriate therapy. Our analysis revealed no evidence of a difference between academic and non-academic centers regarding appropriate usage. Our study revealed there to be high levels of antimicrobial usage at German and Austrian pediatric oncology and hematology centers with a significant higher number at academic centers. Incorrect dosing was shown to be the most frequent reason for inappropriate usage. Diagnosis of febrile neutropenia and antimicrobial stewardship programs were associated with a lower likelihood of inappropriate therapy. These findings suggest the importance of febrile neutropenia guidelines and guidelines compliance, as well as the need for regular antibiotic stewardship counselling at pediatric oncology and hematology centers. European Society of Clinical Microbiology and Infectious Diseases, Deutsche Gesellschaft für Pädiatrische Infektiologie, Deutsche Gesellschaft für Krankenhaushygiene, Stiftung Kreissparkasse Saarbrücken.

Accusation Is Not Proof: Procedural Justice in Psychology

In this article, we explicate a relatively ignored construct in clinical science—procedural justice. Procedural justice is concerned with adjudicative processes in which norms are applied to particular cases in which there is an allegation of some transgression. Psychologists often value social justice, but there can be no social justice without procedural justice. Procedural-justice concerns arise in a wide variety of interpersonal contexts, including diagnoses, administrative adjudications such as ethics complaints or Title IX hearings, conflicts clients experience with others, and more informal contexts such as gossip. Exemplars of problematic procedural justice relevant to psychologists are described. We argue that there are five general dimensions of procedural justice (epistemic, ethical, subjective, legal, and pragmatic) and 20 specific principles of procedural fairness. Suggestions for improved practice and future research are provided. Procedural justice exemplifies values embodied in the late Scott Lilienfeld’s work and life.

The Jurisdiction of the Advertising Regulatory Board over non-members: The Supreme Court of Appeal confirms its Herbex-order in the Bliss-matter

This contribution seeks to answer the following question: To what extent does the Advertising Regulatory Board (ARB), as a public watchdog in the advertising industry, have the jurisdiction to consider advertising complaints filed against a person or entity which is not a member of the ARB? In Advertising Regulatory Board NPC v Bliss Brands (Pty) Ltd 2022 JDR 0769 (SCA), the Supreme Court of Appeal confirmed its earlier order in Advertising Standards Authority v Herbex (Pty) Ltd 2017 6 SA 354 (SCA) that the ARB possesses the jurisdiction to consider an advertising complaint irrespective of whether or not the relevant advertiser is a member of the ARB. Although non-member advertisers may elect not to subject themselves to the jurisdiction of the ARB or comply with an ARB ruling, all ARB rulings are issued for the adherence by the ARB's members. In the instance of a non-member who exercises its constitutional right to dissociate from the ARB and its adjudication process, the ARB may nevertheless consider an advertising complaint if there is a potential contravention of the ARB's Code of Advertising Practice. The SCA's ruling should be considered in the context of the important role that the ARB performs as a service to the general public. While the court a quo in the Bliss-matter attempted to derail this public function, the SCA has come to the aid of the general public in justifying the jurisdiction and public function of the ARB as a body which sets out and rules on ethically acceptable and responsible advertising for the benefit of consumers. Given the advantages of the ARB mechanism as it currently stands, it is submitted that the broader public interest may very well prevail should leave to appeal to the Constitutional Court be granted.

Civil Liability for Deficiency in Medical Services with Special Reference to Surgical Treatments: A Critique of Consumer Protection Act, 1986

The concept of negligence is well illustrated under the various statutory laws in India and all around the world but it’s of grave importance when we coins the term negligence or deficiency in regard to medical services as it poses the question of life and death so it’s of paramount importance to know what constitutes the concept of medical negligence. The duty of doctor towards his patient includes the use of utmost care who is seeking help for his illness. Understanding the concept of deficiency or medical negligence not only helps the doctors in doing their duty without worry but also helps the adjudication process in India to be fast speedy and unprejudiced.

What Factors Are Associated With Early Career Attrition Among Orthopaedic Surgeons in the United States?

The attrition of medical personnel in the United States healthcare system has been an ongoing concern among physicians and policymakers alike. Prior studies have shown that reasons for leaving clinical practice vary widely and may range from professional dissatisfaction or disability to the pursuit of alternative career opportunities. Whereas attrition among older personnel has often been understood as a natural phenomenon, attrition among early-career surgeons may pose a host of additional challenges from an individual and societal perspective. (1) What percentage of orthopaedic surgeons experience early-career attrition, defined as leaving active clinical practice within the first 10 years after completion of training? (2) What are the surgeon and practice characteristics associated with early-career attrition? In this retrospective analysis drawn from a large database, we used the 2014 Physician Compare National Downloadable File (PC-NDF), a registry of all healthcare professionals in the United States participating in Medicare. A total of 18,107 orthopaedic surgeons were identified, 4853 of whom were within the first 10 years of training completion. The PC-NDF registry was chosen because it has a high degree of granularity, national representativeness, independent validation through the Medicare claims adjudication and enrollment process, and the ability to longitudinally monitor the entry and exit of surgeons from active clinical practice. The primary outcome of early-career attrition was defined by three conditions, all of which had to be simultaneously satisfied ("condition one" AND "condition two" AND "condition three"). The first condition was presence in the Q1 2014 PC-NDF dataset and absence from the same dataset the following year (Q1 2015 PC-NDF). The second condition was consistent absence from the PC-NDF dataset for the following 6 years (Q1 2016, Q1 2017, Q1 2018, Q1 2019, Q1 2020, and Q1 2021), and the third condition was absence from the Centers for Medicare and Medicaid Services Opt-Out registry, which tracks clinicians who have formally discontinued enrollment in the Medicare program. Of the 18,107 orthopaedic surgeons identified in the dataset, 5% (938) were women, 33% (6045) were subspecialty-trained, 77% (13,949) practiced in groups of 10 or more, 24% (4405) practiced in the Midwest, 87% (15,816) practiced in urban areas, and 22% (3887) practiced at academic centers. Surgeons not enrolled in the Medicare program are not represented in this study cohort. A multivariable logistic regression model with adjusted odds ratios and 95% confidence intervals was constructed to investigate characteristics associated with early-career attrition. Among the 4853 early-career orthopaedic surgeons identified in the dataset, 2% (78) were determined to experience attrition between the first quarter 2014 and the same point in 2015. After controlling for potential confounding variables such as years since training completion, practice size, and geographic region, we found that women were more likely than men to experience early-career attrition (adjusted OR 2.8 [95% CI 1.5 to 5.0]; p = 0.006]), as were academic orthopaedic surgeons compared with private practitioners (adjusted OR 1.7 [95% CI 1.02 to 3.0]; p = 0.04), while general orthopaedic surgeons were less likely to experience attrition than subspecialists (adjusted OR 0.5 [95% CI 0.3 to 0.8]; p = 0.01). A small but important proportion of orthopaedic surgeons leave the specialty during the first 10 years of practice. Factors most-strongly associated with this attrition were academic affiliation, being a woman, and clinical subspecialization. Based on these findings, academic orthopaedic practices might consider expanding the role of routine exit interviews to identify instances in which early-career surgeons face illness, disability, burnout, or any other forms of severe personal hardships. If attrition occurs because of such factors, these individuals could benefit from connection to well-vetted coaching or counseling services. Professional societies might be well positioned to conduct detailed surveys to assess the precise reasons for early attrition and characterize any inequities in workforce retention across a diverse range of demographic subgroups. Future studies should also determine whether orthopaedics is an outlier, or whether 2% attrition is similar to the proportion in the overall medical profession.

A126 ASSESSING THE QUALITY OF REFERRALS AND ADJUDICATION FOR ENDOSCOPIC RESECTION OF LARGE COLORECTAL POLYPS AT A CANADIAN TERTIARY REFERRAL CENTRE

Abstract Background Management of large colorectal polyps is increasingly complex with the expansion of endoscopic techniques, including endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR), and endoscopic full thickness resection. Adjudicating lesions in an effort to select the optimal resection method is hugely dependent on the information included within the referral. At our institution, a referral pathway based on photo and/or video documentation was created to facilitate the timely assessment and treatment of large colorectal polyps. To date, little is known about quality of referrals for endoscopic resection of large colorectal polyps. Purpose Our study aimed to assess the adjudication process and quality of referrals for endoscopic resection of large colorectal polyps at our advanced endoscopy referral center. Method We conducted a single-center prospective study of consecutive colorectal polyps referred for EMR from March 2021 to March 2022. Cases selected upfront for ESD were excluded. Referral information, intraprocedural data and histology was captured. No procedural and histology data were captured if EMR does not occur after adjudication. The outcome was defined as the frequency of adequate referrals. A referral was deemed adequate if it contained: sufficient photo or video documentation, description of any characteristics that increase the difficulty of endoscopic resection, accurate polyp localization/size estimate (with &amp;lt;1 cm discrepancy when compared to real-time endoscopic evaluation), and description of any endoscopic features of advanced dysplasia (AD), including HGD/IMCa, or submucosal invasion (SMI). Result(s) During the study period, 213 referrals were received for colorectal polyps and underwent adjudication for EMR: 211 underwent EMR; 2 underwent ESD despite being triaged for EMR. Only 5% (10/213) of referrals were deemed to be adequate. Only 34% (73/213) contained any photo or video documentation and only 13% (28/213) photos/videos were of sufficient quality for adjudication. Difficult location or polyp characteristics, if present, were accurately described in 86.7% of referrals (183/211) of referrals. The accurate polyp location was described 80.6% of the time (170/211). Polyp size was estimated in 50.2% (107/213) of referrals. Amongst referrals with size estimated, the size was accurate in 73.8% of the time (79/107). On histological evaluation, 35.1% (74/211) of polyps had AD or SMI. Amongst polyps with AD or SMI, 48.6% (36/74) had endoscopic appearance suggestive of HGD/IMCa/SMI but only 69.4% (25/36) of these polyps with high-risk endoscopic features were accurately predicted based on the referral information. Conclusion(s) Referrals for large colorectal polyps often lack important clinical information. This significantly impairs the ability to adjudicate polyps for triage and resection and may negatively impact patient outcomes. To improve referral adequacy and patient outcomes, we plan to evaluate the impact of polyp adjudication on EMR success. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Risk factor associations with individual myocardial infarction subtypes and acute non-ischemic myocardial injury in the Multi-Ethnic Study of Atherosclerosis (MESA): Design and rationale

Despite different prevalence, pathobiology, and prognosis between etiologically distinct myocardial infarction (MI) subtypes, prospective study of risk factor for MI in large NHLBI-sponsored cardiovascular cohorts is limited to acute MI as a singular entity. Therefore, we sought to utilize the Multi-Ethnic Study of Atherosclerosis (MESA), a large prospective primary prevention cardiovascular study, to define the incidence and risk factor profile of individual myocardial injury subtypes. We describe the rationale and design of re-adjudicating 4,080 events that occurred over the first 14 years of follow-up in MESA for the presence and subtype of myocardial injury as defined by the Fourth Universal Definition of MI: MI type 1 to 5, acute non-ischemic myocardial injury, and chronic myocardial injury. The project utilizes a 2-physician adjudication process via examination of medical records, abstracted data collection forms, cardiac biomarker results, and electrocardiograms of all relevant clinical events. Comparison of the magnitude and direction of associations between baseline traditional and novel cardiovascular risk factors with incident and recurrent acute MI subtypes and acute non-ischemic myocardial injury events will be made. This project will result in one of the first large prospective cardiovascular cohort with modern classification of acute MI subtypes, as well as a full accounting of non-ischemic myocardial injury events, with implications for numerous ongoing and future studies in MESA. By creating precise MI phenotypes, and defining their epidemiology, this project will allow for discovery of novel pathobiology-specific risk factors, allow for development of more accurate risk prediction, and suggest more targeted preventive strategies.

Prevalence, Risk Factors, and Outcomes of Airway Versus Non-Airway Pediatric Extubation Failure.

Pediatric extubation failure is associated with morbidity and mortality. The most common cause is upper-airway obstruction. Subglottic edema is common, but upper-airway obstruction can occur from the oral cavity to the trachea. Dichotomous categorization of extubation failure as airway versus non-airway may help identify risk factors as well as strategies that translate to lower extubation failure rates. This was as single-center, retrospective cohort study of invasive mechanical ventilation encounters within a quality improvement database between October 1, 2017-November 30, 2020. Utilizing a 3-physician adjudication process, all extubation failures were categorized as airway versus non-airway. Primary outcome was failure subtype prevalence. Secondary outcome was failure subtype risk factors. Clinical outcomes were explored. The all-cause extubation failure rate was 10% in a cohort of 844 encounters. Airway and non-airway extubation failure represented 60.7% and 39.3%, respectively. Most airway failures were due to upper-airway obstruction (84.3%)-35.3% were supraglottic, 25.5% subglottic, and 23.5% mixed. Other causes of airway failure were airway patency/secretions (11.8%) and aspiration (3.9%). Non-airway failures were attributed to respiratory failure (75.8%), encephalopathy (15.2%), and other (9%). All-cause extubation failure was associated with dysgenetic/syndromic comorbidity (P = .005), ≥ 3 concurrent comorbid conditions (P = .007), indication for invasive ventilation (P < .001), and longer invasive mechanical ventilation duration (P < .001). Airway extubation failure was significantly associated with the presence of a respiratory comorbidity (P = .01) and Glasgow coma scale < 10 (P = .02). No significant non-airway failure risk factors were identified. Longer pediatric ICU (PICU) stay (P < .001) and PICU mortality (P < .001) were associated with all-cause extubation failure. No significant outcome associations with extubation failure subtype were identified. Airway extubation failure prevalence was 1.5 times higher than non-airway failure. Potential risk factors for airway failure were identified. These findings are hypothesis generating for future study focused on key evidence gaps and pragmatic bedside application.