Recent medical evidence for torture and human rights abuse in Sierra Leone: a report for the Medical Foundation for the Care of Victims of Torture.

A study was carried out using the case notes of all Sierra Leoneans referred to the Medical Foundation for the Care of Victims of Torture between 1996 and 1998 for medical reports. Data were abstracted on the type and extent of torture reported, and the cases were followed up to the present day to ascertain how long the United Kingdom asylum and immigration process had taken to process their claims. In the sample of 36 cases there were 68 reported incidents of torture or human rights abuse. Sixty-nine per cent (18/26) of the women in the sample had been raped at least once, and 72% (26/36) of the sample had been beaten at least once. The average time for the minimum due process of the asylum claim to be processed was 44 months (3.7 years). On 31 January 1999, 61% of the sample (22 people) were still involved in the asylum process. Waiting times must be reduced and safeguards imposed so that those who have suffered torture can be rapidly identified and referred for medical treatment, care and documentation.     

Medical evidence in asylum applications: Medical versus legal approaches

The purpose of this narrative review is to elucidate the ways the clinicians working on forensic medical evaluations can engage with asylum proceedings. We compare the legal and medical perspectives on different aspects of forensic medical evidence, asylum evaluations, and asylum applications. As asylum seekers must demonstrate a well-founded fear of persecution in order to receive asylee status, legal and medical professionals often need to collaborate in asylum cases. Although significant evidence has demonstrated that an objective expert medical opinion can support asylum claims, few studies have analyzed how the medical professional's role complements or is at odds with the goals of the legal system. This review summarizes and compares key aspects of the medical and legal perspectives on trauma, credibility, autobiographical memory, and medical evidence to better comprehend the role that medical professionals can play in writing medical affidavits for asylum applications. We dissect legal misconceptions surrounding trauma and the consequences of such misunderstandings and make recommendations for medical evaluators who are working in a forensic capacity.     

Informed Consent for Interventional Radiology Procedures: A Survey Detailing Current European Practice

Purpose: Official recommendations for obtaining informed consent for interventional radiology procedures are that the patient gives their consent to the operator more than 24 hr prior to the procedure. This has significant implications for interventional radiology practice. The purpose of this study was to identify the proportion of European interventional radiologists who conform to these guidelines. Methods: A questionnaire was designed consisting of 12 questions on current working practice and opinions regarding informed consent. These questions related to where, when and by whom consent was obtained from the patient. Questions also related to the use of formal consent forms and written patient information leaflets. Respondents were asked whether they felt patients received adequate explanation regarding indications for intervention, the procedure, alternative treatment options and complications. The questionnaire was distributed to 786 European interventional radiologists who were members of interventional societies. The anonymous replies were then entered into a database and analyzed. Results: Two hundred and fifty-four (32.3%) questionnaires were returned. Institutions were classified as academic (56.7%), non-academic (40.5%) or private (2.8%). Depending on the procedure, in a significant proportion of patients consent was obtained in the outpatient department (22%), on the ward (65%) and in the radiology day case ward (25%), but in over half (56%) of patients consent or re-consent was obtained in the interventional suite. Fifty percent of respondents indicated that they obtain consent more than 24 hr before some procedures, in 42.9% consent is obtained on the morning of the procedure and 48.8% indicated that in some patients consent is obtained immediately before the procedure. We found that junior medical staff obtained consent in 58% of cases. Eighty-two percent of respondents do not use specific consent forms and 61% have patient information leaflets. The majority of respondents were satisfied with their level of explanation regarding indications for treatment (69.3%) and the procedure (78.7%). Fifty-nine percent felt patients understood alternative treatment options. Only 37.8% of radiologists document possible complications in the patients chart. Comments from respondents indicated that there is insufficient time for radiologists to obtain consent in all patients. Suggestions to improve current local policies included developing the role of radiology nursing staff and the use of radiology outpatient clinics. Conclusions: More than 50% of respondents are unhappy with their policies for obtaining informed consent. Interventional societies have a role to play in advocating formal consent guidelines.     

Rape and attempted rape in Aarhus County, Denmark Police reported and unreported cases

The aim of this study was to compare medical and nonmedical findings in police reported and unreported cases of rape and attempted rape in the county of Aarhus, Denmark, and to explore whether legal outcomes were influenced by medico-legal findings in the cases reported to the police. Data on rapes and attempted rapes were collected from the files of the Department of Forensic Medicine, police reports, and court files. Eighty-seven victims of alleged rape and attempted rape were included in a 14-month period. Of these, 60% were categorized as date rapes, 23% as stranger rapes, and 16% as partner rapes. Sixteen percent did not report the alleged crime to the police, but still participated in a medico-legal examination. Twenty-nine percent filed police reports, but did not have a medico-legal examination undertaken. Extra-genital lesions were more common among the women who filed police reports (63 vs 43%). Women who weee subjected to date rape and partner rape and had not suffered physical injuries were more reluctant to report to the police. Twelve cases were taken to court; 11 offenders were convicted with 1 acquitted. The presence of injuries, vaginal penetration, or the findings of semen, in this study, had not in fluenced the legal outcome.     

Type of consent does not influence patient recall of serious potential radiation toxicity of adjuvant breast radiotherapy

In a sample of 174 women who had received verbal consent (n = 35), general written consent (n = 34) or detailed toxicity-specific written consent (n = 105), no significant differences were found in recall of serious potential toxicities by consent type. Age younger than 70 years and employment outside of the home were significantly associated with better recall. Factors not significantly associated with different recall rates were work status, use of interpreters for consent, time elapsed from treatment or the extent of radiotherapy (tangents only vs other). Overall recall was poor. Twenty-eight percent of women could not correctly recall if their treatment risked any of four nominated complications (lymphoedema, pneumonitis, rib fracture or brachial plexopathy). Significant numbers of women erroneously attributed a number of 'complications' or symptoms to radiotherapy.     

The prevalence of major depressive disorder and anxiety disorders among asylum seekers in South Florida

The rapidly growing population of asylum seekers in the United States often seeks asylum following persecution and severe traumatic events. Asylum evaluations play an influential role in the process by objectively documenting human rights abuses. The purpose of this study was to describe the prevalence of major depressive disorder (MDD) and anxiety disorders among asylum seekers and analyze differences in the severity of disease by time and sub-group. Data was collected from a retrospective review of medical affidavits written from 2017 to 2020 following asylum evaluations in South Florida. Decision trees were utilized to make diagnoses for each individual's current mental health status in the U.S. and retrospectively for while in their home country. These diagnoses were recorded according to the Global Burden of Disease study criteria and utilizing validated mental health screeners. The prevalence of MDD was found to significantly decrease from 75.8% in patients' home countries to 46.7% in the U.S. Similarly, prevalence of anxiety disorders significantly fell from 85.8% to 64.2%. Gender and being a victim of sexual assault were significantly associated with severity of MDD and anxiety disorders. This reduction in the burden of mental health disease after relocation to the United States demonstrate the benefit of asylum not only as a human right, but also as a mental health intervention. Through their connection with higher application success rates and referrals to follow-up care, physician-performed asylum evaluations can thus be linked to improved health outcomes.     

Failed female sterilization and the law

The word sterilization suggests a permanent state of affairs but there have always been some failures after both male and female sterilization operations; as a result there has been a marked increase in legal actions for failed sterilization. 2 types of legal actions taken for failed sterilization in the UK are 1) the tort of negligence or the tort of trespass to the person (assault and battery), and 2) the breach of contract. This paper lists some of the court cases surrounding the issue of failed sterilization, and discusses the issue of consent. Some of these court cases and their decisions are: 1) Udale v. Bloomsbury Area Health Authority (1984)--damages for the birth of a child are against public policy; 2) Emeh v. kensington, Chelsea and Fulham Area Health Authority and others (1983)--pregnancy constitutes an injury where there is lack of warning about the possibility of failure; and 3) Thake and another v. Maurice--absence of warning about risk of failure is a breach of contract. The cases of Emeh and Thake establish that the patient must be told about the failure rate of sterilization procedures. Consent in the UK requires sufficient explanation of the procedure to enable the patient to make up his or her mind about the operation. Caution must be exercised when the sterilization is performed at the end of a caesarean section; there is a high failure rate when the sterilization is performed in this situation. US and Canadian courts require a higher standard of disclosure before the patient is considered to have enough information to allow her to give informed consent. The patient should be told in no uncertain terms about the possiblity of failure and the importance of reporting subsequent amenorrhea or pregnancy symptoms. The word sterilization suggests a permanence that cannot be guaranteed; therefore, oral and written records must be maintained. The operation should be called occlusion and be considered a more lasting form of contraception which is difficult to reverse.     

Physician care for interscholastic athletes in Michigan

Between January 1989 and March 1989 the athletic directors of the 711 high schools in the Michigan High School Athletic Association were surveyed as to what sports and levels of competition each school offered and what level of medical care was available. Fifty-seven percent of the surveyed schools returned properly completed forms. Sixty-one percent of the schools responding reported having a physician available for at least one team at some time during the year. This was almost universally the football team; with 59% of the schools with varsity football reporting a physician present at either a practice or a contest at least once during the year. Only 13% of the schools reported having a physician available for a team other than varsity football. Seventy-four percent of all varsity teams had neither a physician nor an athletic trainer present at any time during the year. Comparison of the results of this study with similar studies performed in Michigan in 1975 and 1979, as well as studies in other states, demonstrates that despite the increased awareness and popularity of sports medicine, there has been no appreciable change in the amount of access interscholastic athletes have to physician care.     

Intentional burn injury: Assessment of allegations of self-infliction

This study investigates the question of whether there is evidence that suggests the possibility of self-infliction, or self-infliction by proxy, of burn injury among a group of asylum claimants in the UK who have attributed such injuries to torture, and how such evidence might be assessed. The question arose from the observations of doctors at the UK-based charity Freedom from Torture that increasing numbers of individuals from Sri Lanka who described a history of torture had suffered severe and disfiguring burn injuries from heated metal objects, and the suggestion from asylum decision-makers that in some cases such injuries could have been acquired deliberately by self-infliction or self-infliction by proxy rather than by torture as claimed. This suggestion has not been confined to Sri Lankan cases, but due to the large numbers of Sri Lankan asylum claimants referred to Freedom from Torture in recent years, including many with this type of injury, the case set for this study was drawn from this population. As many of these injuries are found to be on the back, where self-infliction would be extremely difficult, the possibility of self-infliction by proxy was specifically investigated.An observational data set was examined in detail, comprising medico-legal reports for Sri Lankans with heated metal object burn injuries documented in 2011–14 by the Medico-Legal Reports Service at Freedom from Torture. All had described detention in Sri Lanka since the end of the civil war in 2009. The study reviewed the documented evidence of these injuries alongside other physical and psychological evidence attributed to torture and relevant contextual factors documented in each case. Findings were compared with previous research on torture in Sri Lanka and patterns of injury identified in forensic medicine for both self-infliction and self-infliction by proxy. Thorough examination of the evidence found no indication in this data set to suggest the possibility of self-infliction or self-infliction by proxy and supported the view that, as indicated in the Istanbul Protocol, the overall conclusion on likelihood of torture should be made on evaluation of all the physical and psychological evidence over and above the scrutiny of an individual lesion.     

High-grade decubitus ulcers in the elderly

Some elderly persons develop high-grade decubitus ulcers, whereas others with comparable risk factors do not. In Germany, forensic pathologists are increasingly confronted by situations that necessitate an expert opinion on whether prevention of decubitus ulcers has been neglected in cases of suspected malpractice. This investigation was carried out in an attempt to identify risk factors for decubitus ulcers. We performed a postmortem case-control study in elderly persons who developed high-grade decubitus ulcers from 6 months to 14 days before death. Deceased with decubitus ulcers graded 3 or higher and controls at comparable risk were examined before cremation. After written informed consent had been obtained from the nearest living relatives, all available nursing and medical records of the deceased were thoroughly evaluated. Decubitus ulcer cases and controls were matched according to age, gender, immobility, and cachexia. One-hundred cases of decubitus ulcers with 71 grade 3 decubitus ulcers and 29 grade 4 decubitus ulcers were compared with 100 controls with 27 decubitus ulcers graded 2 or lower and the maximal risk as assessed by the Norton scale. The mean age was 86 years, 80% were females, 86% were bedridden, and cachexia was found in 66%. The individuals with decubitus ulcers were more often severely disabled, had more immobility of joints, and were more often under treatment with antidepressive and/or sedative drugs (e.g., opioid analgesies, neurolepties, benzodiazepines). Patients’ impaired ability or unwillingness to comply or cooperate with preventive and therapeutic measures was more often recorded in cases of decubitus than in the control group. There was no evidence that supplementary nutrition or use of preventive pressure relief and protective devices differed between the decubitus cases and the controls.     

Radiology review of the UKCCCR Breast Screening Frequency Trial: potential improvements in sensitivity and lead time of radiological signs

AIM: To review all previous mammograms of breast cancer cases diagnosed during a randomized trial comparing 3 yearly to annual mammographic screening with a view to identifying and quantifying cases that might potentially have been diagnosed earlier. METHODS: Mammograms of 602 breast cancer cases (399 screen-detected and 203 interval cases) were reviewed in chronological order and suspicious radiological features noted for each mammogram, up to and including the diagnostic mammogram. RESULTS: Of the 602 cases, 79 (13%) had features at diagnosis that were visible on previous mammograms, suggesting a sensitivity of interpretation of 87%. A similar proportion of screen-detected (14%) and interval cancers (11%) had signs at diagnosis that were visible on previous mammograms. The potential for improvement was particularly noted for asymmetric density (sensitivity = 77%, average time visible before diagnosis 14 months) and parenchymal deformity/stellate lesion (sensitivity = 81%, average time visible before diagnosis 12 months). CONCLUSION: The highest sensitivity was observed for comedo-type microcalcifications (sensitivity = 97%, average time visible before diagnosis 5 months). By improvements in sensitivity to asymmetric density and parenchymal deformity/stellate lesion, 4% of tumours could have their time of diagnosis advanced substantially.     

A retrospective study of all low birth-weight preterm babies born in BMH Rinteln between 1980-1989

A retrospective study was undertaken of all preterm babies born in BMH Rinteln between 1980-88 weighing less than 2500g. The total proportion of low birth weight babies was 7% and 58% of these were preterm (454 babies). Sixty per cent of women presented after the spontaneous rupture of membranes or in established labour. Conservative management of ruptured membranes, whilst not leading to life-threatening sepsis, did not significantly prolong pregnancy. Sixteen percent of the babies were very low birth weight (under 1500g). Delivery of these infants by Caesarean section when presenting by the breech improved survival, although this was not statistically significant. Thirty percent of all babies were delivered by Caesarean section before 36 weeks, reflecting obstetric emergencies in the mother which predisposed to preterm delivery. Neonatal survival depended on both gestational maturity and birth weight and was not significantly better in babies who were low birth weight for gestational age. These infants however represented 75% of the still-births and congenital abnormalities. Sixty percent of the mothers smoked and 50% had other identifiable risk factors for preterm delivery; 20% of the multiparous patients had previously experienced a perinatal death, preterm delivery or had a baby with intra-uterine growth retardation. It is suggested that preterm delivery is a significant problem in an Army population despite full employment, adequate housing and comprehensive medical care. Attempts to stop labour are unlikely to be successful. Effort should be made antenatally to identify those women who may be at risk of "idiopathic" preterm labour, as patient education programmes have been shown to decrease the incidence.     

Swipe right: the emergence of dating-app facilitated sexual assault. A descriptive retrospective audit of forensic examination caseload in an Australian metropolitan service

The use of dating ‘apps’ to facilitate real-word social encounters between strangers is culturally mainstream. Sexual assaults facilitated following dating-app meetings have been reported in the media, and anecdotally noted at increasing frequency by clinical forensic physicians. Limited empirical data suggests there has been a marked increase in real life sexual offences facilitated in this manner. There is little additional information known about the circumstances of these alleged incidents. This retrospective audit of a small forensic examination caseload from an Australian metropolitan clinical forensic medicine service identified that 14% (11 of 76) of alleged sexual assaults where complainants underwent a forensic examination were facilitated following a dating-app meeting. Further analysis of these cases identified that all complainants were female, most under 30 years of age. All alleged a single male perpetrator and in over half of the cases the complainant was impaired. In all cases where it was asked (n = 9), the alleged incident occurred at the first face-to-face meeting. More than half of the incidents occurred at the alleged perpetrator’s private residence. Anogenital injuries were observed at the time of forensic examination in 60% of cases, and 70% had visible body injuries. There was no reported condom use. Only one complainant had no observable injury. This small case series quantified a high proportion of forensic sexual assault examination caseload as being facilitated by dating-app meetings, and identified some common features that may be characteristic of alleged sexual assaults occurring in this manner. The authors propose a larger prospective period of data collection at the time of forensic medical examination, to characterize the features of sexual assaults allegedly occurring following app-based meetings.     

Comparative approaches to the nonconsensual sterilization of the mentally retarded

Laws governing the sterilization of persons so mentally retarded as to be unable themselves to consent to the procedure have left a trail of manifest abuses right around the globe, and no less in North America than elsewhere. Ostensibly, as a kind of rebound effect, courts in North America, and most obviously in Canada, have erected substantial legal obstacles in the path of those seeking the sterilization of such a retarded individual. Historically, such abuses have been of a lesser scale, or at least have been much less manifest, in Great Britain. In the absence of any significant negative legacy, courts in Britain would seem to have developed a more balanced and equitable, although not necessarily more reasoned, approach to the determination of such cases to the seeming benefit of many seriously retarded persons. Ironically, these same courts hinder their own efforts in relation to retarded adults by denying jurisdiction in such cases and refusing to seek an adequate remedy for the lacuna.     

Sterilization of mentally retarded individuals: informed consent in Guidelines in the Netherlands

The purpose of this paper is to describe and discuss the Guidelines of the Dutch Health Care Inspectorate' with respect to sterilization of mentally retarded individuals. In 1998, the Minister of Health had the 1989 Guidelines replaced by new ones. Two new laws were integrated into these new Guidelines: the Medical Treatment Agreement Act (hereinafter referred to as WGBO, being the Dutch abbreviation) and the Mentorship Act. The minister was also inspired to draw up new Guidelines by the revelation in the media of involuntary sterilizations still taking place in several European countries. She is adamant that the Guidelines should be a 'guarantee against involuntary sterilizations'. This issue requires special guidelines because of judicial questions connected with the sterilization of individuals who are more or less incapable of giving informed consent. Involuntary sterilization is a violation of basic human rights, such as the right of physical integrity and protection of privacy. The Guidelines describe how the decision-making process between doctor, patient, representatives, proxies or guardians should proceed and what to do when parties do not reach consensus. A distinction has been made between competent and incompetent patients. The Guidelines and the WGBO give answers to questions like the following: will the informed consent of representatives and proxies be sufficient to perform sterilization? Do doctors have to follow representatives and proxies? Can sterilization take place in spite of a patient's resistance? The Guidelines focus on the process of decision-making, in order to guarantee an appropriate procedure, with the best possible outcome for the mentally retarded individual. The Guidelines do not answer the question of what legitimate reasons doctors may have for performing sterilization on such a person. Given the substantial questions involved the Minister of Health has asked the Health Council to add possible grounds to the Guidelines that should be taken into account when deciding on sterilization.     

Definitive radiation therapy for endometrial cancer in medically inoperable elderly patients

PurposeWith the increasing elderly population, more women with newly diagnosed endometrial cancer may not be surgical candidates due to medical comorbidities. Definitive radiation therapy with external beam radiation (EBRT) and/or brachytherapy is a reasonable primary treatment for endometrial cancer in patients who cannot undergo surgery.MethodsA retrospective review identified 26 women 75 years and older with endometrial cancer who were not operative candidates due to comorbidities and received definitive radiation.ResultsThe median age of the treated patients was 83, all of whom had significant medical comorbidities precluding surgical treatment. Seventy-three percent of the patients had stage T1 disease, 19% were stage T2, and 8% were stage T3. Seventy-three percent of patients received EBRT before brachytherapy (median dose: 45 Gy). The median brachytherapy dose was 20 Gy in 5 fractions. The types of brachytherapy used were Rotte Y applicator (42%), tandem and cylinder (42%), and ring and tandem (16%). Median followup was 12 months (1–60 months). No treatment breaks were required for the entire group and only 2 patients (8%) developed late toxicity. The overall survival for all patients was 89% and 28% at 1 and 2 years, respectively. Disease-specific survival for all patients was 93% at 1 year and 73% at 3 years.ConclusionsThe results in this study indicate that definitive radiation with EBRT and/or brachytherapy for endometrial cancer is feasible and well tolerated in an elderly population.     

Do written consent forms provide medicolegal protection from litigation in radiotherapy?

Two methods were used in an attempt to determine whether written consent forms serve a useful medicolegal purpose in Australian radiotherapy departments. First a survey was posted to all practising radiation oncologists to ask about their use of written consent forms and whether they had ever been useful in any claims made against them. Second, the largest medical defence organization in Australia was contacted for de-identified details about every claim ever made against a radiation oncologist. The survey yielded a response rate of 50.3%. Only one respondent indicated that any consent form had ever played a role in any claim and was not prepared to discuss it. Many radiation oncologists did not routinely use a consent form and its use could not be considered standard practice. The submitted consent forms generally did not contain warnings to the patient about specific risks of treatment. The details of the previous claims provided by the medical defence organization indicated that more often claims arose from circumstances in which a written consent form could not provide any useful protection such as radiation dose calculation errors. The medicolegal value of written consent forms in radiotherapy seems low, although further research may be necessary before dispensing with them completely.     

Hydrosalpinx and tubal torsion: a late complication of tubal ligation

Two women who had been sterilized by tubal ligation or cautery experienced recurrent pelvic pain several years later, and cystic adnexal masses were recognized in both patients. Both patients had bilateral hydrosalpinges with unilateral torsion and gangrene. These cases suggest there may be a predisposition to hydrosalpinx and tubal torsion following tubal ligation if the fimbriated end of the fallopian tube becomes occluded. Awareness of this potential complication may lead to increased recognition and earlier intervention in patients who have undergone tubal ligation.