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Transthoracic echocardiography (TTE) is routinely required during pre-participation screening in the presence of symptoms, family history of sudden cardiac death or cardiomyopathies <40-year-old, murmurs, abnormal ECG findings or in the follow-up of athletes with a history of cardiovascular disease (CVD). TTE is a cost-effective first-line imaging modality to evaluate the cardiac remodeling due to long-term, intense training, previously known as the athlete's heart, and to rule out the presence of conditions at risk of sudden cardiac death, including cardiomyopathies, coronary artery anomalies, congenital, aortic and heart valve diseases. Moreover, TTE is useful for distinguishing physiological cardiac adaptations during intense exercise from pathological behavior due to an underlying CVD. In this expert opinion statement endorsed by the Italian Society of Sports Cardiology, we discussed common clinical scenarios where a TTE is required and conditions falling in the grey zone between the athlete's heart and underlying cardiomyopathies or other CVD. In addition, we propose a minimum dataset that should be included in the report for the most common indications of TTE in sports cardiology clinical practice., Competing Interests: Declaration of competing interest The authors report no relationships that could be construed as a conflict of interest. All authors have seen and approved the manuscript being submitted, have contributed significantly to the work, attest to the validity and legitimacy of the data and its interpretation, and agree to its submission to the International Journal of Cardiology., (Copyright © 2024. Published by Elsevier B.V.)

The article presents the description of 3 fatal cases of subjects with alcohol abuse in past medical history under xenotherapy procedure. The formulation of diagnoses and judgements on death causes of victims are shown. "Blind spots" in the expertise of death cases under the xenotherapy procedure are discussed.

The article presents the results of analysis of 482 forensic biological and forensic cytological expertises on cases of sexual crimes. A presence of different types of such crimes has been noted. Expertises' effectiveness when examining content of vagina, oral cavity and rectum, impression smears and lavages from suspects' genital organs, subungual content of victims and suspects and other objects has been determined. The dependence of expertises' effectiveness on the terms of object removal has been noted. The article presents a number of objects' examination methods (luminescent-microscopic spermatozoids' identification, diagnosis of cells origin from mucous membranes of the vagina and oral cavity, determination of group belonging of specific cells in specimens, diagnosis of fecal masses presence) allowing to improve expertises' quality.

The article presents the main innovative methods used in forensic expert practice at the current stage, reveals the principle and algorithms of the developed software complex for registration and identification of the deceased. The proposed program automatically generates four documents, which reduces the time required for forensic expertise in the conditions of mass admission of deceased. The article's authors substantiate prospects of further application of computer technologies in forensic practice to improve organizational and methodological activities in emergencies with a large number of deceased.

The article is devoted to legal and forensic medical problems of postmortem donation. The substantive provisions of postmortem donation, as well as normative legal documents regulating the processes of organs harvesting from deceased persons for subsequent transplantation and governing the work of transplantologists and forensic medical experts have been considered. The practical examples illustrating the essence and nature of the problem of postmortem forensic medical expertise of persons with absent organs has been given and the importance of the participation of a forensic medical expert involved in the decision-making process on possibility (or impossibility) of the corpse's organs and tissues explantation without prejudice to the further expert examination has been emphasized. The authors pay particular attention to the inadequacy of the legal framework, including the lack of a clear understanding of the legal status of the person holding the position of forensic medical expert, who provides an expert opinion on the organs' explantation.

Death from general hypothermia is one of the leading causes in the structure of violent death in the Russian Federation., Objective: To clarify and supplement the complex of differential diagnostic macro- and microscopic signs of a fatal acute general cold trauma received when person is in the air and water., Material and Methods: The conclusions of forensic medical experts on the bodies of people who died from hypothermia in the air and in water (by 150 observations) were analyzed. Methods of descriptive statistics, calculation of the frequency ratio of signs' occurrence were used., Results: The article provides quantitative assessment of occurrence (detection) rate of diagnostically significant signs established with the help of traditional methods of expert examination. A new classification of diagnostic death signs from hypothermia taking into account their differential diagnostic significance and reflecting the conditions of a person's stay in the air and water in the pre-mortem and post-mortem periods, as well as terminal period mechanisms is proposed., Conclusion: The established complexes of signs provide an objective basis for determining death cause in non-obvious conditions when cold exposure is expected to be one of the most damaging factors.

Background: The RAND/UCLA Appropriateness Method (RAM), a variant of the Delphi Method, was developed to synthesize existing evidence and elicit the clinical judgement of medical experts on the appropriate treatment of specific clinical presentations. Technological advances now allow researchers to conduct expert panels on the internet, offering a cost-effective and convenient alternative to the traditional RAM. For example, the Department of Veterans Affairs recently used a web-based RAM to validate clinical recommendations for de-intensifying routine primary care services. A substantial literature describes and tests various aspects of the traditional RAM in health research; yet we know comparatively less about how researchers implement web-based expert panels., Objective: The objectives of this study are twofold: (1) to understand how the web-based RAM process is currently used and reported in health research and (2) to provide preliminary reporting guidance for researchers to improve the transparency and reproducibility of reporting practices., Methods: The PubMed database was searched to identify studies published between 2009 and 2019 that used a web-based RAM to measure the appropriateness of medical care. Methodological data from each article were abstracted. The following categories were assessed: composition and characteristics of the web-based expert panels, characteristics of panel procedures, results, and panel satisfaction and engagement., Results: Of the 12 studies meeting the eligibility criteria and reviewed, only 42% (5/12) implemented the full RAM process with the remaining studies opting for a partial approach. Among those studies reporting, the median number of participants at first rating was 42. While 92% (11/12) of studies involved clinicians, 50% (6/12) involved multiple stakeholder types. Our review revealed that the studies failed to report on critical aspects of the RAM process. For example, no studies reported response rates with the denominator of previous rounds, 42% (5/12) did not provide panelists with feedback between rating periods, 50% (6/12) either did not have or did not report on the panel discussion period, and 25% (3/12) did not report on quality measures to assess aspects of the panel process (eg, satisfaction with the process)., Conclusions: Conducting web-based RAM panels will continue to be an appealing option for researchers seeking a safe, efficient, and democratic process of expert agreement. Our literature review uncovered inconsistent reporting frameworks and insufficient detail to evaluate study outcomes. We provide preliminary recommendations for reporting that are both timely and important for producing replicable, high-quality findings. The need for reporting standards is especially critical given that more people may prefer to participate in web-based rather than in-person panels due to the ongoing COVID-19 pandemic., (©Jordan B Sparks, Mandi L Klamerus, Tanner J Caverly, Sarah E Skurla, Timothy P Hofer, Eve A Kerr, Steven J Bernstein, Laura J Damschroder. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 26.08.2022.)

The forensic assessment of testamentary capacity is a topical issue given the prevalence of dementia illnesses and the increase in the complexity of modern financial and family structures. Although a contemporaneous assessment would be desirable, the majority of situations require a retrospective assessment of the mental state a deceased individual. Neuropsychologists, independently or as part of a board of consultants, are, therefore, frequently requested to give an expert opinion of the competence of cognitively impaired elderly testators.This paper offers a guide for carrying out a neuropsychological autopsy, namely the process of posthumous evaluation, for determining testamentary capacity. Taking into account the recent literature on the assessment of testamentary capacity, we propose a three-phase procedure for carrying out the neuropsychological autopsy in the forensic context. The neuropsychological autopsy of testamentary capacity is based on the meticulous, chronologically structured evaluation of any medical documents, available psychometric data, along with the critical examination of any source of information about the cognitive level of functioning of the deceased person at the time of the will.

Background: In model-based economic evaluations, the effectiveness parameter is often informed by studies with a limited duration of follow-up, requiring extrapolation of the treatment effect over a longer time horizon. Extrapolation from short-term data alone may not adequately capture uncertainty in that extrapolation. This study aimed to use structured expert elicitation to quantify uncertainty associated with extrapolation of the treatment effect observed in a clinical trial., Methods: A structured expert elicitation exercise was conducted for an applied study of a podiatry intervention designed to reduce the rate of falls and fractures in the elderly. A bespoke web application was used to elicit experts' beliefs about two outcomes (rate of falls and odds of fracture) as probability distributions (priors), for two treatment options (intervention and treatment as usual) at multiple time points. These priors were used to derive the temporal change in the treatment effect of the intervention, to extrapolate outcomes observed in a trial. The results were compared with extrapolation without experts' priors., Results: The study recruited thirty-eight experts (geriatricians, general practitioners, physiotherapists, nurses, and academics) from England and Wales. The majority of experts (32/38) believed that the treatment effect would depreciate over time and expressed greater uncertainty than that extrapolated from a trial-based outcome alone. The between-expert variation in predicted outcomes was relatively small., Conclusions: This study suggests that uncertainty in extrapolation can be informed using structured expert elicitation methods. Using structured elicitation to attach values to complex parameters requires key assumptions and simplifications to be considered.

Purpose: In a comparator study, designed with assistance from the Food and Drug Administration, a State-of-the-Art (SOTA) ECG device augmented with automated analysis, the comparator, was compared with a breakthrough technology, Cardio-HART (CHART)., Methods: The referral decision defined by physician reading biosignal-based ECG or CHART report were compared for 550 patients, where its performance is calculated against the ground truth referral decision. The ground truth was established by cardiologist consensus based on all the available measurements and findings including echocardiography (ECHO)., Results: The results confirmed that CHART analysis was far more effective than ECG only analysis: CHART reduced false negative rates 15.8% and false positive (FP) rates by 5%, when compared with SOTA ECG devices. General physicians (GP's) using CHART saw their positive diagnosis rate significantly increased, from ~10% to ~26% (260% increase), and the uncertainty rate significantly decreased, from ~31% to ~1.9% (94% decrease). For cardiology, the study showed that in 98% of the cases, the CHART report was found to be a good indicator as to what kind of heart problems can be expected (the 'start-point') in the ECHO examination., Conclusions: The study revealed that GP use of CHART resulted in more accurate referrals for cardiology, resulting in fewer true negative or FP-healthy or mildly abnormal patients not in need of ECHO confirmation. The indirect benefit is the reduction in wait-times and in unnecessary and costly testing in secondary care. Moreover, when used as a start-point, CHART can shorten the echocardiograph examination time., Competing Interests: Competing interests: GBZ: disclosure: consulted for Cardionovum, CrannMed, InnovHeart, Meditrial, Opsens Medical and Replycare. IK: disclosure: Director, UVA research, no other industry connections. TS: no relationships to Industry. ES: no relationship to industry ABS, no relationship to industry., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Healthcare systems have reached a critical point regarding the question of whether biosimilar substitution should become common practice. To move the discussion forward, the study objective was to investigate the views of experts from medicines agencies and the pharmaceutical industry on the science underpinning interchangeability of biosimilars. We conducted an empirical qualitative study using semi-structured interviews informed by a cross-disciplinary approach encompassing regulatory science, law, and pharmaceutical policy. In total 25 individuals with experience within biologics participated during September 2018-August 2019. Eight participants were EU national medicines authority regulators, and 17 had pharmaceutical industry background: five from two originator-only companies, four from two companies with both biosimilar and originator products, and eight from seven biosimilar-only companies. Two analysts independently conducted inductive content analysis, resulting in data-driven themes capturing the meaning of the data. The participants reported that interchangeability was more than a scientific question of likeness between biosimilar and reference products: it also pertained to regulatory practices and trust. Participants were overall confident in the science behind exchanging biosimilar products for the reference products via switching, i.e., with physician involvement. However, their opinions differed regarding the scientific risk associated with biosimilar substitution, i.e., without physician involvement. Almost all participants saw no need for additional scientific data to support substitution. Moreover, the participants did not believe that switching studies, as required in the US, were appropriate for obtaining scientific certainty due to their small size. It is unclear why biosimilar switching is viewed as scientifically safer than substitution; therefore, we expect greater policy debate on biosimilar substitution in the near future. We urge European and UK policymakers and regulators to clarify their visions for biosimilar substitution; the positions of these two frontrunners are likely to influence other jurisdictions on the future of biosimilar use., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: LCD was funded by a PhD fellowship grant to the University of Copenhagen from LEO Pharma A/S, but the company has no commercial interest in the research. This does not alter our adherence to PLOS ONE policies on sharing data and materials. ” There are data restrictions which we have described in the data availability statement: “The minimal data set underlying the results has been supplied in the manuscript (the quotes are raw data), additional data cannot be shared publicly because this would compromise anonymity and confidentiality of the participants.

Intraocular lens (IOL) power calculations are less accurate in eyes that have undergone corneal refractive surgery. A wide range of methods have been proposed. We reviewed the methods and outcomes of IOL power calculations in eyes with previous LASIK, excimer laser photorefractive keratectomy (PRK), or radial keratotomy (RK). The PubMed database was searched for articles that (1) discuss methods and outcomes of IOL power calculation in eyes with previous corneal refractive surgery and (2) evaluate the outcomes of toric, multifocal, or extended depth-of-focus (EDOF) IOLs in these eyes. We excluded review articles, case reports or case studies, and non-English reports. Seventy full-text articles were included in this review. Three categories of methods exist based on whether and how they use historical data acquired before the corneal refractive surgery. The American Society of Cataract and Refractive Surgery (ASCRS) postrefractive IOL calculator incorporates many commonly used methods. In eyes with previous myopic LASIK or PRK, hyperopic LASIK or PRK, and RK, 0% to 85%, 38.1% to 71.9%, and 29% to 87.5% of eyes, respectively, showed refractive prediction errors within ±0.5 diopter (D); in eyes with toric IOL implantation that met certain inclusion criteria, 80%, 84%, and 69% of eyes, respectively, achieved postoperative astigmatism of 0.50 D or less. Intraocular lenses with negative spherical aberration (SA) will reduce the positive corneal spherical aberration induced in eyes by myopic LASIK or PRK or by RK. Intraocular lenses with 0 SA on average best match corneal SA in eyes with prior hyperopic LASIK or PRK. Studies have reported excellent outcomes of postrefractive eyes implanted with multifocal or EDOF IOLs; however, corneal topographic enrollment criteria were not specified. Despite availability of new measurement technologies and development of new IOL calculation formulas, further advances are needed to improve outcomes of cataract surgery in eyes that have undergone corneal refractive surgery. Tools like the ASCRS postrefractive IOL calculator are useful for the clinician by incorporating a variety of formulas. Toric, EDOF, and multifocal IOLs may provide excellent outcomes in selected cases that meet certain corneal topographic criteria., (Copyright © 2020 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Spinal muscular atrophy (SMA) is an autosomal recessive, neurodegenerative disease caused by biallelic mutations in the survival motor neuron 1 (SMN1) gene. SMA is characterized by motor neuron degeneration, resulting in progressive muscle atrophy and weakness. Before the emergence of disease-modifying therapies, children with the most severe form of SMA would never achieve the ability to sit independently. Only 8% survived beyond 20 months of age without permanent ventilator support. One such therapy, onasemnogene abeparvovec, an adeno-associated virus-based gene replacement therapy, delivers functional human SMN through a one-time intravenous infusion. In addition to substantially improving survival, onasemnogene abeparvovec was found to increase motor milestone attainment and reduce the need for respiratory or nutritional support in many patients. This expert opinion provides recommendations and practical considerations on the patient-centered decisions to use onasemnogene abeparvovec. Recommendations include the need for patient-centered multidisciplinary care and patient selection to identify those with underlying medical conditions or active infections to reduce risks. We also describe the importance of retesting patients with elevated anti-adeno-associated virus serotype 9 antibodies. Recommendations for prednisolone tapering and monitoring for potential adverse events, including hepatotoxicity and thrombotic microangiopathy, are described. The need for caregiver education on managing day-to-day care at time of treatment and patient- and family-centered discussions on realistic expectations are also recommended. We detail the importance of following standard-of-care guidance and long-term monitoring of all children with SMA who have received one or more disease-modifying therapy using registries. We also highlight the need for presymptomatic or early symptomatic treatment of this disorder., (© 2021 The Authors. Muscle & Nerve published by Wiley Periodicals LLC.)

Expertise in science, particularly in animal behaviour, may provide people with the capacity to provide better judgments in contrast to lay people. Here we explore whether experts provide a more objective, accurate and coherent evaluation of a recently reported anecdote on Atlantic puffin (Fratercula arctica) "tool use" (recorded on video) which was published in a major scientific journal but was received with some scepticism. We relied on citizen science and developed a questionnaire to measure whether experts in ethology and ornithology and lay people agree or disagree on (1) the description of the actions that they observe (the bird takes a stick in its beak), (2) the possible goal of the action (nest-building or grooming) and (3) the intentional component of the action (the bird took the stick into its beak in order to scratch itself). We hypothesised that contrary to the lay people, experts are more critical evaluators that is they are more inclined to report alternative actions, like nest building, or are less likely to attributing goal-directedness to the action in the absence of evidence. In contrast, lay people may be more prone to anthropomorphise utilising a teleological and intentional stance. Alternatively, all three groups of subjects may rely on anthropomorphism at similar levels and prior expertise does not play a significant role. We found that no major differences among the evaluators. At the group levels, respondents were relatively uncertain with regard to the action of the bird seen on the video but they showed some individual consistency with regard to the description of the action. Thus, we conclude that paradoxically, with regard to the task our experts are typically not experts in the strict sense of the definition, and suggest that anecdotal reports should not be used to argue about mental processes., (© 2021. The Author(s).)

Objectives: COVID19 pandemic has forced physicians from different specialties to assist cases overload. Our aim is to assess gastroenterologist's assistance in COVID-19 by assessing mortality, ICU admission, and length of stay, and seek for risk factors for in-hospital mortality and longer hospital stay., Methods: A total of 41 COVID-19 patients assisted by gastroenterologist (GI cohort) and 137 assisted by pulmonologist, internal medicine practitioners, and infectious disease specialists (COVID expert cohort) during October-November 2020 were prospectively collected. Clinical, demographic, imaging, and laboratory markers were collected and compared between both cohorts. Bivariate analysis and logistic regression were performed to search for risk factors of mortality and longer hospital stays., Results: A total of 27 patients died (15.1%), 11 were admitted to ICU (6.1%). There were no differences between cohorts in mortality (14.6% vs 15.4%;p = 0.90), ICU admission (12.1% vs 4%;p = 0.13), and length of stay (6.67 ± 4 vs 7.15 ± 4.5 days; p = 0.58). PaO2/FiO2 on admission (OR 0.991;CI95% 0.984-0.998) and age > 70 (OR 17.54;CI95% 3.93-78.22) were independently related to mortality. Age > 70, history of malignancy, diabetes, and cardiovascular disease were related to longer hospital stays (p < 0.001, p = 0.03, p = 0.04, p = 0.02 respectively)., Conclusions: COVID-19 assistance was similar between gastroenterologist and COVID experts when assessing mortality, ICU admission, and length of stay. Age>70 and decreased PaO2/FiO2 on admission were independent risk factors of mortality. Age and several comorbidities were related to longer hospital stay.

Background: Each of the cardiomyopathies, classically categorized as hypertrophic cardiomyopathy, dilated cardiomyopathy (DCM), and arrhythmogenic right ventricular cardiomyopathy, has a signature genetic theme. Hypertrophic cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy are largely understood as genetic diseases of sarcomere or desmosome proteins, respectively. In contrast, >250 genes spanning >10 gene ontologies have been implicated in DCM, representing a complex and diverse genetic architecture. To clarify this, a systematic curation of evidence to establish the relationship of genes with DCM was conducted., Methods: An international panel with clinical and scientific expertise in DCM genetics evaluated evidence supporting monogenic relationships of genes with idiopathic DCM. The panel used the Clinical Genome Resource semiquantitative gene-disease clinical validity classification framework with modifications for DCM genetics to classify genes into categories on the basis of the strength of currently available evidence. Representation of DCM genes on clinically available genetic testing panels was evaluated., Results: Fifty-one genes with human genetic evidence were curated. Twelve genes (23%) from 8 gene ontologies were classified as having definitive ( BAG3 , DES , FLNC , LMNA , MYH7 , PLN , RBM20 , SCN5A , TNNC1 , TNNT2 , TTN ) or strong ( DSP ) evidence. Seven genes (14%; ACTC1 , ACTN2 , JPH2 , NEXN , TNNI3 , TPM1 , VCL ) including 2 additional ontologies were classified as moderate evidence; these genes are likely to emerge as strong or definitive with additional evidence. Of these 19 genes, 6 were similarly classified for hypertrophic cardiomyopathy and 3 for arrhythmogenic right ventricular cardiomyopathy. Of the remaining 32 genes (63%), 25 (49%) had limited evidence, 4 (8%) were disputed, 2 (4%) had no disease relationship, and 1 (2%) was supported by animal model data only. Of the 16 evaluated clinical genetic testing panels, most definitive genes were included, but panels also included numerous genes with minimal human evidence., Conclusions: In the curation of 51 genes, 19 had high evidence (12 definitive/strong, 7 moderate). It is notable that these 19 genes explain only a minority of cases, leaving the remainder of DCM genetic architecture incompletely addressed. Clinical genetic testing panels include most high-evidence genes; however, genes lacking robust evidence are also commonly included. We recommend that high-evidence DCM genes be used for clinical practice and that caution be exercised in the interpretation of variants in variable-evidence DCM genes.

Regulatory changes have been enacted in the United States (US) and European Union (EU) to encourage the development of new treatments for pediatric cancer. Here, we review some of the factors that have hampered the development of pediatric cancer treatments and provide a comparison of the US and EU regulations implemented to address this clinical need. We then provide some recommendations for each stage of the oncology drug development pathway to help researchers maximize their chance of successful drug development while complying with regulations. A key recommendation is the engagement of key stakeholders such as regulatory authorities, pediatric oncologists, academic researchers, patient advocacy groups, and a Pediatric Expert Group early in the drug development process. During drug target selection, sponsors are encouraged to consult the Food and Drug Administration (FDA), European Medicines Agency (EMA), and the FDA target list, in addition to relevant US and European consortia that have been established to characterize and prioritize oncology drug targets. Sponsors also need to carefully consider the resourcing requirements for preclinical testing, which include ensuring appropriate access to the most relevant databases, clinical samples, and preclinical models (cell lines and animal models). During clinical development, sponsors can account for the pharmacodynamic (PD)/pharmacokinetic (PK) considerations specific to a pediatric population by developing pediatric formulations, selecting suitable PD endpoints, and employing sparse PK sampling or modeling/simulation of drug exposures where appropriate. Additional clinical considerations include the specific design of the clinical trial, the potential inclusion of children in adult trials, and the value of cooperative group trials., (© 2021. The Author(s).)

Objectives: Many experts feel that in the absence of well-defined goals for success, they have an easier time identifying failure. As success ought to not be defined only by absence of failure, we aimed to define optimal outcomes for endoscopic sinus surgery (ESS) in chronic rhinosinusitis (CRS) by obtaining expert surgeon perspectives., Methods: A total of 12 surgeons participated in this targeted consultation. Face to face semi-structured interviews were performed with expert surgeons in the field of CRS and ESS. General impressions and personal definitions of acceptable operative success and optimal operative outcomes were compiled and summarized., Results: According to an expert survey, patients' main objectives are an improvement in their chief complain, a general improvement in quality of life (QoL), and a better overall symptomatic control. The most important aspects of endoscopy for defining a successful intervention were an adequate mucus circulation, a healthy mucosa, minimal edema, and patency of all explored cavities or ostia. In the assessment of surgical outcomes, it was determined that both objective and patient reported data must be carefully examined, with more attention given to subjective outcomes., Conclusions: According to data gathered from a Canadian expert consultation, a definition of success must be based on both subjective data and nasal endoscopy. We propose to define an acceptable outcome as either a subjective improvement of at least the minimal clinically improvement difference of a validated patient reported outcome questionnaire, along with a satisfactory endoscopic result (1) or a complete subjective resolution with a sub-optimal endoscopy (2).

Purpose: Recent reports have described a spectrum of uncommon findings of intraocular inflammation (IOI), retinal vasculitis, or retinal vascular occlusion in patients with neovascular age-related macular degeneration (nAMD) treated with intravitreal injection (IVI) of brolucizumab. We present guidance on the clinical presentation of this spectrum and propose recommendations for management of these events., Design: PubMed literature review and expert opinion panel., Participants: A working group of international medical experts and Novartis medical personnel., Methods: The working group deliberated on the clinical presentations and used a 3-pronged approach to develop management recommendations based on (1) critical appraisal of scientific literature; (2) clinical insights from the HAWK and HARRIER trials, postmarketing reports, and assessments from an independent Safety Review Committee (SRC); and (3) their clinical experience., Main Outcome Measures: Management recommendations for a spectrum of ocular inflammatory events after treatment with brolucizumab or other anti-vascular endothelial growth factors (VEGFs)., Results: Based on insights gained from the available information and the expertise of the contributors, recommendations were proposed for ocular examinations, imaging modalities, and treatment strategies for management of this spectrum of events. Patients should be educated to promptly report any relevant or persistent symptoms after IVI to facilitate timely intervention. Patients diagnosed with IOI should be evaluated for concomitant retinal vasculitis or retinal vascular occlusive events. Clinical examination can be augmented with multimodal imaging techniques, including widefield imaging, fluorescein angiography (with peripheral sweeps), and OCT. Once confirmed, the ongoing brolucizumab treatment should be suspended and intensive treatment with potent corticosteroids (topical, subtenon, intravitreal, or systemic) is recommended, which may be supplemented with other treatment strategies depending on the severity. Based on the clinical outcome of these events, individualized treatment with locally available standard of care should be considered for the underlying nAMD., Conclusions: These recommendations emphasize the need for early diagnosis, prompt and timely intervention, intensive treatment, and frequent monitoring to minimize the risk of progression of these events. The proposed recommendations may facilitate a consistent management approach of this spectrum of ocular inflammatory events should they arise in nAMD after treatment with brolucizumab or other anti-VEGFs., (Copyright © 2020 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Objective: The present research examined whether concurrent expert testimony ("hot tubbing") and court-appointed testimony reduced adversarial allegiance in clinical experts' judgments compared with traditional adversarial expert testimony., Hypotheses: We predicted Hypothesis 1: Defense experts would render more not responsible judgments and lower ratings of criminal responsibility than would prosecution experts; Hypothesis 2: Adversarial allegiance effects on experts' judgments would be heightened for adversarial experts and attenuated for concurrent experts over time; Hypothesis 3: Adversarial and concurrent experts would report higher dissonance than would court-appointed experts and adversarial experts' ratings would increase over time, concurrent experts' ratings would decrease, and court-appointed experts' ratings would remain unchanged., Method: Clinicians and advanced clinical doctoral students conducted simulated criminal responsibility evaluations for the prosecution, defense, or court. We categorized participants as favoring the prosecution or defense based on their preexisting attitudes and randomly assigned them to the adversarial, concurrent, or court-appointed expert testimony conditions. Participants completed a dichotomous responsibility judgment, strength of responsibility ratings, and cognitive dissonance measure after initial evidence review (n = 93), report completion (n = 52), and testimony (n = 48). Concurrent experts generated a joint report outlining areas of agreement and disagreement before providing testimony., Results: Concurrent testimony did not eliminate adversarial allegiance. Adversarial and concurrent experts' perceptions of responsibility did not significantly differ (d = .04, 95% CI [-.64, .71]) or change over time (ηp2 = .03); however, prosecution experts-across testimony types-rated the defendant as significantly more responsible than did defense experts (d = 1.87, 95% CI [1.06, 2.67]). Concurrent and adversarial experts did not differ in their reports and minimally differed in testimony content., Conclusions: Experts who initially favored the prosecution or defense showed adversarial allegiance regardless of expert testimony method, and we observed no attenuation of this bias over the course of their case involvement. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Study Design: Survey study., Objective: Assess practices and opinions of spine specialists from Europe and North America on orthosis use in adult patients with acute thoracolumbar (TL) fractures. Evaluate cost of the devices., Summary of Background Data: Although orthosis are traditionally used in conservative treatment of TL fractures, recent systematic reviews showed no benefit in patient's outcomes., Methods: A search for contact authors with publications on spine fractures from all European and North American countries was performed. An online questionnaire was sent on demographic data, practice setting, mean number of fractures treated, use of orthosis upon choice for conservative treatment, and average orthosis cost. Data was analyzed based in world regions, economic rank of the country, and health expenditure., Results: We received 130 answers, from 28 European and five North American countries. Most responders had more than 9 years of practice and worked at a public hospital. 6.2% did not prescribe a brace in any patient with acute TL fractures conservatively treated and 11.5% brace all patients. In a scale from 1 to 5, 21 considered that there is no/low benefit (1) and 14 that bracing is essential (5), with a mean of 3.18. Europeans use orthosis less commonly than North Americans (P < 0.05). Orthosis mean cost was $611.4 ± 716.0, significantly higher in North America compared with Europe and in high income, when compared with upper middle income countries (both P < 0.05). Although hospital costs were not evaluated, orthosis is costlier when it involves admission of the patient (P < 0.05). An increase in orthosis cost associated with higher gross domestic product (GDP) per capita and higher health expenditure was found., Conclusion: More than 90% of spine specialists still use orthosis in conservative treatment of adult patients with acute TL fractures. Orthosis cost vary significantly between continents, and it is influenced by the country's economy.Level of Evidence: 4., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The risk of complications, including death, is substantially increased in patients with pulmonary hypertension (PH) undergoing anaesthesia for surgical procedures, especially in those with pulmonary arterial hypertension (PAH) and chronic thromboembolic PH (CTEPH). Sedation also poses a risk to patients with PH. Physiological changes including tachycardia, hypotension, fluid shifts, and an increase in pulmonary vascular resistance (PH crisis) can precipitate acute right ventricular decompensation and death., Methods: A systematic literature review was performed of studies in patients with PH undergoing non-cardiac and non-obstetric surgery. The management of patients with PH requiring sedation for endoscopy was also reviewed. Using a framework of relevant clinical questions, we review the available evidence guiding operative risk, risk assessment, preoperative optimisation, and perioperative management, and identifying areas for future research., Results: Reported 30 day mortality after non-cardiac and non-obstetric surgery ranges between 2% and 18% in patients with PH undergoing elective procedures, and increases to 15-50% for emergency surgery, with complications and death usually relating to acute right ventricular failure. Risk factors for mortality include procedure-specific and patient-related factors, especially markers of PH severity (e.g. pulmonary haemodynamics, poor exercise performance, and right ventricular dysfunction). Most studies highlight the importance of individualised preoperative risk assessment and optimisation and advanced perioperative planning., Conclusions: With an increasing number of patients requiring surgery in specialist and non-specialist PH centres, a systematic, evidence-based, multidisciplinary approach is required to minimise complications. Adequate risk stratification and a tailored-individualised perioperative plan is paramount., (Copyright © 2021 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Recent research on second-generation long-acting injectable antipsychotics (LAI SGAs) has proven its effectiveness in minimizing medication nonadherence problem and reducing relapses. Administered by medical professionals, making quick detection of nonadherence possible, long-acting injectable antipsychotics (LAIs) facilitate immediate intervention and recovery process, and thus are favored by psychiatrists. Despite a higher initial cost with LAIs, the subsequent schizophrenia-related health costs for hospitalizations and outpatients are greatly reduced. With reference to guidelines published by psychiatric associations around the globe, this article looks at scenarios in Hong Kong on the management of severe mentally ill patients with regard to the use of a host of psychosocial interventions as well as LAI SGAs as a preferable treatment. In particular, it examines the benefits of using LAI SGAs for Hong Kong patients who demonstrated high nonadherence treatment rates due to their social environment. It assesses the rationale behind the early usages of LAI SGAs, which help to provide better recovery outcomes for patients., (© 2021 The Authors. CNS Neuroscience & Therapeutics Published by John Wiley & Sons Ltd.)

Poisoning and envenomation are a global health problem for which the mortality burden is shouldered heavily by middle- and low-income countries that often lack poison prevention programs and medical toxicology expertise. Although telehealth or teleconsult services have been used to bridge the expertise gap between countries for multiple specialties, the use of medical toxicology teleconsult services across borders has been limited. We aim to describe the use of a United States-based medical toxicology teleconsult service to support patient care at a hospital in a middle-income country that lacks this expertise. This report outlines the logistics involved in setting up such a service, including the challenges and opportunities that emerged from establishing medical toxicology teleconsult service in a low-resource setting.

COVID-19 has caused great devastation in the past year. Multi-organ point-of-care ultrasound (PoCUS) including lung ultrasound (LUS) and focused cardiac ultrasound (FoCUS) as a clinical adjunct has played a significant role in triaging, diagnosis and medical management of COVID-19 patients. The expert panel from 27 countries and 6 continents with considerable experience of direct application of PoCUS on COVID-19 patients presents evidence-based consensus using GRADE methodology for the quality of evidence and an expedited, modified-Delphi process for the strength of expert consensus. The use of ultrasound is suggested in many clinical situations related to respiratory, cardiovascular and thromboembolic aspects of COVID-19, comparing well with other imaging modalities. The limitations due to insufficient data are highlighted as opportunities for future research.

Introduction: Historically, there has been variability in the methods for determining preventable death within the US Department of Defense. Differences in methodologies partially explain variable preventable death rates ranging from 3% to 51%. The lack of standard review process likely misses opportunities for improvement in combat casualty care. This project identified recommended medical and non-medical factors necessary to (1) establish a comprehensive preventable death review process and (2) identify opportunities for improvement throughout the entire continuum of care., Methods: This qualitative study used a modified rapid assessment process that includes the following steps: (1) identification and recruitment of US government subject matter experts (SMEs); (2) multiple cycles of data collection via key informant interviews and focus groups; (3) consolidation of information collected in these interviews; and (4) iterative analysis of data collected from interviews into common themes. Common themes identified from SME feedback were grouped into the following subject areas: (1) prehospital, (2) in-hospital and (3) forensic pathology., Results: Medical recommendations for military preventable death reviews included the development, training, documentation, collection, analysis and reporting of the implementation of the Tactical Combat Casualty Care Guidelines, Joint Trauma System Clinical Practice Guidelines and National Association of Medical Examiners autopsy standards. Non-medical recommendations included training, improved documentation, data collection and analysis of non-medical factors needed to understand how these factors impact optimal medical care., Conclusions: In the operational environment, medical care must be considered in the context of non-medical factors. For a comprehensive preventable death review process to be sustainable in the military health system, the process must be based on an appropriate conceptual framework implemented consistently across all military services., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Lennox-Gastaut syndrome (LGS) is a severe developmental epileptic encephalopathy diagnosed in childhood that persists through adolescence and into adulthood. While the characteristics of LGS in pediatric patients are well defined, including "drop attacks", interictal slow spike and wave electroencephalogram (EEG) activity, and intellectual disability, these features can evolve over time, and different EEG activities may be present in adult patients with LGS. This may result in missed diagnoses in these patients and subsequent challenges for the adequate treatment of their seizures. Based on discussions held during the LGS Transition of Care advisory board meeting and thereafter, we developed proposed diagnostic and treatment algorithms for LGS in adult patients. We highlight readily available assessments to facilitate diagnosis of LGS, based on past medical history and physical examination. The LGS diagnostic algorithm recommends that clinicians consider the occurrence of wider seizure types and abnormal EEG activities to be potentially indicative of LGS. Seizure types may include atypical absence seizures, myoclonic seizures, focal seizures, and tonic-clonic seizures, and EEG may demonstrate background slowing, focal or multifocal epileptiform discharges, and diffuse fast rhythms during sleep, among other activities. Extended EEG during sleep and video-EEG should be used in equivocal cases. Treatment of LGS in adult patients should incorporate both antiseizure drug (ASD) therapy and nonpharmacologic approaches. Frequent reassessment of patients is considered a central aspect. ASDs were categorized based on order of preference for use in the treatment of LGS; Tier 1 comprises recommended first-line ASDs, and includes valproate, clobazam, lamotrigine, rufinamide, topiramate, and cannabidiol. Other treatment options include diet, neurostimulation, and surgical approaches. Developments with the potential to improve diagnosis in the future include genetic screening, while novel ASDs and advances in neurostimulation techniques may provide valuable treatment options. These algorithms should be frequently revisited to incorporate improved techniques and therapies., Competing Interests: Declaration of competing interest Georgia Montouris has served on advisory boards for Eisai and SK Life Science, and has served on a safety board for UCB Pharma. Sami Aboumatar has served on advisory boards and/or has carried out consulting work for Eisai and Sunovion. David Burdette has served on advisory boards for Eisai and SK Life Science; has received speaker bureau honoraria from Eisai, Greenwich Biosciences, NeuroPace, Sunovion, and UCB Pharma; and has received research grant support from Eisai, NeuroPace, and Zogenix. Sanjeev Kothare and Ruben Kuzniecky have served on an advisory board for Eisai. William Rosenfeld has served on advisory boards for Eisai and SK Life Science; serves as a consultant for SK Life Science; has received speaker bureau honoraria from Eisai, Sunovion, and UCB Pharma; and has received research grant support from Greenwich Biosciences, Neurelis, Ovid Therapeutics, SK Life Science, Takeda, and UCB Pharma. Steve Chung has served on advisory boards for Eisai, SK Life Science, Sunovion, and UCB Pharma; has received speaker bureau honoraria from Eisai, Lundbeck, Sunovion, and UCB Pharma; and has received research grant support from SK Life Science and UCB Pharma., (Copyright © 2020 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: To understand the opinions of clinicians about the risks, benefits, barriers, and facilitators to the practice of parent sleep during skin-to-skin care in hospital settings., Design: Cross-sectional survey., Setting: Online survey., Participants: Clinicians who self-identified as infant care providers, that is, neonatal clinicians (N = 158)., Methods: We sent an online survey invitation to neonatal clinicians through neonatal websites, conferences, and social media sites in the United States and used snowball recruitment. We used a risk management framework to analyze qualitative data. We used descriptive statistics and the chi-square and Fisher's exact tests to determine if opinions differed based on clinician and organizational characteristics., Results: Respondents' support of parent sleep during skin-to-skin care (yes/no) did not differ on the basis of whether the clinician had taken a formal course on skin-to-skin care, facilitated skin-to-skin care more than 100 times, or frequently promoted skin-to-skin care in current practice. Respondents who supported parent sleep (n = 93, 59% of respondents) reported greater implementation of risk control strategies than nonsupporters (n = 53 [57%] vs. n = 3 [5%]; p < .001), such as frequent monitoring of vital signs (n = 33 [35%] vs. n = 2 [3%]; p < .001), use of devices to support skin-to-skin care (n = 49 [53%] vs. n = 19 [29%]; p = .003), and proper positioning (n = 20 [22%] vs. n = 0 [0%]; p < .001). Nonsupporters more frequently reported that parent sleep during skin-to-skin care violates safe sleep recommendations, is habit forming for home, poses a fall risk, and jeopardizes the infant's airway., Conclusion: Most respondents supported parent sleep during skin-to-skin care, but concerns regarding safety for the infant remained a barrier. The use of a risk management framework may help facilitate a systematic approach to improve the implementation of safe skin-to-skin practices., (Copyright © 2020 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.)

Background: Chiari I Malformation (CMI) and the topics concerning it have been the subject of numerous discussions and polarizing controversies over the course of the past 20 years., Methods: The opinions of 63 recognized international Neurosurgical CMI experts from 4 continents, with a collective surgical experience of more than 15,000 CMI cases, were gathered through a detailed questionnaire, divided in two parts: diagnostic and therapeutic. The therapeutic part was organized into four sections: Professional Profile, Technical Preferences, Surgical Opinions, and Clinical Scenarios., Results: The data reflected a wide spectrum of opinions, approaches, and expertise. The second part of the questionnaire dealt with the surgical aspects of CMI care and painted a more complex picture: • 81% of the surgeons preferred the Intradural technique. • 88% of the experts agreed that CMI surgery is not indicated for minimal non-debilitating symptoms alone, or as prophylaxis. • In the face of given clinical scenarios, a wide spectrum of therapeutic approaches was chosen by the whole group, but the 4 Surgeons with the largest case series expressed the same opinion. • Eight out of 63 Surgeons had a surgical experience above 600 cases, were responsible for more than half of the total 15,000 declared CMI cases, and shared a similar profile in terms of technical surgical choices, therapeutic opinions, and low complication rate, with a marked preference for Intradural techniques and tonsillar manipulation. • Once large individual case series were accumulated, we did not see any differences in the opinions and preferences between Adult and Pediatric Neurosurgeons., Conclusion: Surgeons who have focused on CMI have been able to accumulate large surgical series, have chosen in their practices the more aggressive (and intrinsically more effective) CMI surgical techniques, and have achieved a low complication rate which compares favorably with that one of the extradural techniques., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: During the peak of the COronaVIrus Disease 2019 (COVID-19) pandemic, care for patients with gastrointestinal motility and functional disorders was largely suspended. In the recovery phases of the pandemic, non-urgent medical care is resumed, but there is a lack of guidance for restarting and safely conducting motility and function testing. Breath tests and insertion of manometry and pH-monitoring probes carry a risk of SARS-CoV-2 spread through droplet formation., Methods: A panel of experts from the European Society for Neurogastroenterology and Motility (ESNM) evaluated emerging national and single-center recommendations to provide the best current evidence and a pragmatic approach to ensure the safe conduct of motility and function testing for both healthcare professionals and patients., Results: At a general level, this involves evaluation of the urgency of the procedure, evaluation of the infectious risk associated with the patient, the investigation and the healthcare professional(s) involved, provision of the test planning and test units, education and training of staff, and use of personnel protection equipment. Additional guidance is provided for specific procedures such as esophageal manometry, pH monitoring, and breath tests., Conclusions and Inferences: The ESNM guidelines provide pragmatic and appropriate guidance for the safe conduct of motility and function testing in the COVID-19 pandemic and early recovery phase., (© 2020 John Wiley & Sons Ltd.)

Objectives: Vascular access device decision-making for pediatric patients remains a complex, highly variable process. To date, evidence-based criteria to inform these choices do not exist. The objective of the Michigan Appropriateness Guide for Intravenous Catheters in pediatrics (miniMAGIC) was to provide guidance on device selection, device characteristics, and insertion technique for clinicians, balancing and contextualizing evidence with current practice through a multidisciplinary panel of experts., Methods: The RAND Corporation and University of California, Los Angeles Appropriateness Method was used to develop miniMAGIC, which included the following sequential phases: definition of scope and key terms, information synthesis and literature review, expert multidisciplinary panel selection and engagement, case scenario development, and appropriateness ratings by an expert panel via 2 rounds., Results: The appropriateness of the selection, characteristics, and insertion technique of intravenous catheters commonly used in pediatric health care across age populations (neonates, infants, children, and adolescents), settings, diagnoses, clinical indications, insertion locations, and vessel visualization devices and techniques was defined. Core concepts including vessel preservation, insertion and postinsertion harm minimization (eg, infection, thrombosis), undisrupted treatment provision, and inclusion of patient preferences were emphasized., Conclusions: In this study, we provide evidence-based criteria for intravenous catheter selection (from umbilical catheters to totally implanted venous devices) in pediatric patients across a range of clinical indications. miniMAGIC also highlights core vascular access practices in need of collaborative research and innovation., Competing Interests: POTENTIAL CONFLICT OF INTEREST: Dr Ullman reports investigator-initiated research grants and speaker fees provided to Griffith University from vascular access product manufacturers (3M Medical, AngioDynamics, Becton Dickinson, Cardinal Health) unrelated to the current project. Dr Bernstein reports grants from the Agency for Healthcare Research and Quality and the US Department of Veterans Affairs. Dr Doellman reports honoraria from Genentech and Lineus Medical and consulting with Teleflex Medical unrelated to this project. Dr Gore reports honoraria for invited talks in patient safety and patient advocacy. Ms Kleidon reports investigator-initiated research grants and speaker fees provided to Griffith University from 3M Medical, AngioDynamics, Baxter, BD-Bard, Centurion, Cook Medical, Medical Specialties Australia, and Vygon (unrelated to the current project). Dr Wolf reports participation in research sponsored by Astellas Inc, Cempra Pharmaceuticals Inc, and Merck Inc and in-kind research support from Karius Inc and Carefusion Inc. Ms Pitts reports employment by B. Braun Medical and St Joseph’s Children’s Hospital, Tampa, Florida, previous employment and stockholder status with AngioDynamics, and board membership of Navi Medical Technologies. Dr Cooke reports investigator-initiated research grants and speaker fees provided to Griffith University by vascular access product manufacturers (Baxter, Becton Dickinson, Entrotech Life Sciences) unrelated to this project. Dr Rickard reports investigator-initiated research grants and speaker fees provided to Griffith University from vascular access product manufacturers (3M, AngioDynamics, Baxter, B. Braun Medical, BD-Bard; Medtronic, ResQDevices, Smiths Medical) unrelated to this project. Dr Chopra reports grants from the Agency for Healthcare Research and Quality and American Hospital Association, book royalties from Oxford University Press for The Saint-Chopra Guide to Inpatient Medicine, and honoraria for invited external talks as a visiting professor; the other authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

Introduction: Ethnobotanical studies that include participatory methods aim to engage residents in different steps to promote the strengthening and perpetuation of local culture, and empowerment in making decisions about the use of available environmental resources. Thus, the aim of this project was to perform an ethnobotanical survey based on traditional knowledge of medicinal plants with the active participation of residents living in Bairro do Cambury, Ubatuba, São Paulo State, Brazil., Materials and Methods: During meetings held between the researchers and community members, locally used plants were regarded as an important means for preserving local knowledge for future generations. Some residents showed interest in participating as local partners, and training courses for collecting ethnobotanical data were offered. Local partners and researchers from São Paulo Federal University (Universidade Federal de São Paulo) utilized ethnobotanical methods to select and interview the specialists in medicinal plants for 80 days between 2016 and 2018. Data on plant use were recorded, and plants were collected and deposited in two herbaria. Furthermore, participant observation and fieldwork diaries were used by the researchers, aiding the data analysis., Results: Three local partners participated in objective definitions, data collection, analysis and publication. Nine local specialists were interviewed by the local partners and indicated the use of 82 plant species in 90 recipes for 55 therapeutic uses. These uses were grouped into 12 categories. In addition, a video and booklet were created., Conclusions: Data obtained during participatory research show that training local communities in the registration of their own knowledge is feasible and necessary since they register knowledge based on local perceptions, as well as valuing knowledge and approaching the current discussion about intellectual property is a global concern., Competing Interests: The authors have declared that no competing interests exist.

Well-established methods of economic evaluation are used in many countries to inform decisions about the funding of new medical interventions. To guide such decisions, it is important to consider what health gains would be expected from the same level of investment elsewhere in the health care system. Recent research in the United Kingdom has evaluated the evidence available and the methods required to estimate the health effects of changes in health care expenditure within the National Health Service. Because of the absence of sufficiently broad-ranging data, assumptions were required in the previously mentioned work to estimate health effects in terms of a broader measure of health (quality-adjusted life-years), which is more relevant for policy. These assumptions constitute important sources of uncertainty. This work presents an application of the structured elicitation of the judgments of key individuals about these uncertain quantities. This article describes the design and conduct of the exercise, including the quantities elicited, the individual (rather than consensus) approach used, how uncertainty in knowledge was elicited (mode and bounds of an 80% credible interval), and methods to generate group estimates. It also reports on a successful application involving 28 clinical experts and 25 individuals with policy responsibilities. Although, as expected, most experts found replying to the questions challenging, they were able to express their beliefs quantitatively. Consistent across the uncertainties elicited, experts' judgments suggest that the quality-adjusted life-year (QALY) impacts of changes in expenditure from earlier work using assumptions are likely to have been underestimated and the "central" estimate of health opportunity cost from that work (£12,936 per QALY) to have been overestimated.

Objective: The aim of this study was to gather the expert opinions of Korean epileptologists regarding the treatment of adult patients with epilepsy., Methods: A total of 42 neurologists who specialized in epilepsy were surveyed. They completed an online questionnaire describing multiple patient scenarios. Using these scenarios, they evaluated treatment strategies and gave their preference for specific antiepileptic drugs (AEDs) used to treat genetically mediated generalized epilepsy and focal epilepsy., Results: Initial AED monotherapy, followed by a second form of alternative monotherapy or an add-on combination therapy, was the preferred treatment strategy. The experts reached consensus for 87.2% of the items. The most commonly selected AEDs for the initial monotherapy for patients with generalized epilepsy were levetiracetam or valproate. For those with focal epilepsy, levetiracetam, oxcarbazepine, or lamotrigine were the most popular selections. Ethosuximide was the treatment of choice only for patients with generalized epilepsy with prominent absence seizures. Levetiracetam was preferred as an add-on therapy for both generalized and focal epilepsy. For special populations of patients, such as elderly adults or those with comorbid diseases, levetiracetam or lamotrigine was selected as the treatment of choice., Conclusion: Most of the survey results were in accordance with the US expert opinion survey published in 2016. This survey can assist clinicians in making clinical decisions when treating individual adult patients with epilepsy., Competing Interests: Declaration of competing interest None., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Aim: Although criteria and recommendations for the successful integration of sex- and gender-sensitive aspects in medical teaching have already been published, only a few medical faculties in Germany have conducted the systematic integration of sex- and gender-sensitive medicine. The aim of this expert survey, therefore, was to describe the current approaches to the integration of sex- and gender-sensitive medicine in teaching in the sense of Good Practice. Method: Between April and June 2018, guided interviews were conducted with nine experts in the field of sex- and gender-sensitive medicine. Each of the experts had had experience of implementing sex- and gender-sensitive medicine at their universities. The expert interviews were then evaluated by means of quality content analysis, and frequency analyses were carried out. Results: Aspects of sex- and gender-sensitive medicine were integrated both longitudinally and selectively into the compulsory curriculum or elective fields of various medical, health and nursing science courses. In the opinion of the experts, medical studies should promote the students' gender sensitivity and in particular impart knowledge about the psychosocial and biological aspects of sex- and gender-related differences and sex- and gender-sensitive communication. For the methodological implementation of the integrated contents, didactic resources were partly adapted or developed. The players in the implementation process were confronted with various challenges, e.g. the involvement of the lecturers, the perception of sex- and gender-sensitive medicine as a women's theme as well as ensuring the sustainable integration of sex- and gender-sensitive medicine, which is also structurally anchored in the faculty. Aspects of the curricular integration (e.g. evidence-basing, relevance in examinations) and the structural anchoring (e.g. central organization, staff availability) were mentioned i.a. as being crucial for success. A combination of top-down and bottom-up processes, e.g. by involving the faculty management but also by supporting student initiatives, was described as conducive to success. Conclusion: The depicted approaches to the integration of sex- and gender-sensitive teaching contents give insight as to how sex- and gender-sensitive medicine can be integrated into the curricula. The interviews with the experts point to current themes related to sex- and gender-sensitive medicine and didactic resources. Moreover, it becomes clear which challenges are to be expected for the integration of sex- and gender-sensitive medicine in teaching and how these can be addressed. Particularly the involvement of the faculty's lecturers but also the sustainable integration and continual quality assurance of sex- and gender-sensitive contents present challenges of a crucial nature., Competing Interests: The authors declare that they have no competing interests., (Copyright © 2020 Clever et al.)

Proactively including the ethical and societal issues of new technologies could have a positive effect on their acceptance. These issues could be captured in terms of values. In the literature, the values stakeholders deem important for the development of technology have often been identified. However, the relative ranking of these values in relation to each other have not been studied often. The best worst method is proposed as a possible method to determine the weights of values, hence it is used in an evaluative fashion. The applicability of the method is tested by applying it to the case of smart meters, one of the main components of the smart grid. The importance of values is examined for three dimensions of acceptance namely sociopolitical, market, and household acceptance.

Purpose: Patient blood management [PBM] has been acknowledged and successfully introduced in a wide range of medical specialities, where blood transfusions are an important issue, including anaesthesiology, orthopaedic surgery, cardiac surgery, or traumatology. Although pregnancy and obstetrics have been recognized as a major field of potential haemorrhage and necessity of blood transfusions, there is still little awareness among obstetricians regarding the importance of PBM in this area. This review, therefore, summarizes the importance of PBM in obstetrics and the current evidence on this topic., Method: We review the current literature and summarize the current evidence of PBM in pregnant women and postpartum with a focus on postpartum haemorrhage (PPH) using PubMed as literature source. The literature was reviewed and analysed and conclusions were made by the Swiss PBM in obstetrics working group of experts in a consensus meeting., Results: PBM comprises a series of measures to maintain an adequate haemoglobin level, improve haemostasis and reduce bleeding, aiming to improve patient outcomes. Despite the fact that the WHO has recommended PBM early 2010, the majority of hospitals are in need of guidelines to apply PBM in daily practice. PBM demonstrated a reduction in morbidity, mortality, and costs for patients undergoing surgery or medical interventions with a high bleeding potential. All pregnant women have a significant risk for PPH. Risk factors do exist; however, 60% of women who experience PPH do not have a pre-existing risk factor. Patient blood management in obstetrics must, therefore, not only be focused on women with identified risk factor for PPH, but on all pregnant women. Due to the risk of PPH, which is inherent to every pregnancy, PBM is of particular importance in obstetrics. Although so far, there is no clear guideline how to implement PBM in obstetrics, there are some simple, effective measures to reduce anaemia and the necessity of transfusions in women giving birth and thereby improving clinical outcome and avoiding complications., Conclusion: PBM in obstetrics is based on three main pillars: diagnostic and/or therapeutic interventions during pregnancy, during delivery and in the postpartum phase. These three main pillars should be kept in mind by all professionals taking care of pregnant women, including obstetricians, general practitioners, midwifes, and anaesthesiologists, to improve pregnancy outcome and optimize resources.

Background: The diagnosis of antiphospholipid syndrome requires detection of antiphospholipid antibodies (aPL). A retrospective review of our testing practices revealed that societal recommendations for lupus anticoagulant (LA) testing as part of aPL testing are largely not followed by clinicians, and there was a high proportion of positive LA results. Increasing direct oral anticoagulant (DOAC) usage creates additional challenges in identifying LA. This prompted us to establish an order set with pathologist consultation ("LA panel") and testing algorithm to reduce false-positive LA and to ensure optimal LA identification and best practices for interpretation and follow-up., Methods: The laboratory database was reviewed to determine the number of LA tests ordered and rate of LA positivity before and after the LA panel was instituted. We assessed the impact of pathologist consultation to minimize false-positive findings and on following diagnostic guidelines., Results: LA panels were ordered for 1146 patients. LA was detected in 10% (111 of 1146) by dilute Russel viper venom time (dRVVT) normalized ratio [includes dRVVT screen (dRVVTs) positive/lupus-sensitive partial thromboplastin time (PTT-LA) positive and dRVVTs positive/PTT-LA negative] and 20% (228 of 1146) by Staclot-LA (includes dRVVTs negative/PTT-LA positive and dRVVTs positive/confirm negative). There was a reduction of false-positive LA by Staclot-LA; previously, 48% positive. We saw increased cancellation of LA testing for interfering anticoagulants [6.8% (16 of 236) vs 14.4% (55 of 383); P = 0.0061]. There was also increased adherence to follow-up LA testing [3% (8 of 236) vs 13.8% (53 of 383); P ≤ 0.001]., Conclusions: Creating a predetermined order set and testing algorithm with pathologist consultation improved LA testing interpretation and diagnostic follow-up testing., (© 2019 American Association for Clinical Chemistry.)

Activity level evaluations, although still a major challenge for many disciplines, bring a wealth of possibilities for a more formal approach to the evaluation of interdisciplinary forensic evidence. This paper proposes a practical methodology for combining evidence from different disciplines within the likelihood ratio framework. Evidence schemes introduced in this paper make the process of combining evidence more insightful and intuitive thereby assisting experts in their interdisciplinairy evaluation and in explaining this process to the courts. When confronted with two opposing scenarios and multiple types of evidence, the likelihood ratio approach allows experts to combine this evidence in a probabilistic manner. Parts of the prosecution and defence scenarios for which forensic science is expected to be informative are identified. For these so called core elements, activity level propositions are formulated. Afterwards evidence schemes are introduced to assist the expert in combining the evidence in a logical manner. Two types of evidence relations are identified: serial and parallel evidence. Practical guidelines are given on how to deal with both types of evidence relations when combining the evidence., (Copyright © 2019 The Chartered Society of Forensic Sciences. Published by Elsevier B.V. All rights reserved.)

Percutaneous coronary intervention (PCI) is establishing as the last remaining revascularization option in an increasing number of patients affected by complex coronary artery disease not suitable for surgery. Over the past decade, percutaneous left ventricular assist device (pLVAD) has increasingly replaced intra-aortic balloon pump to provide hemodynamic support during such non-emergent complex high-risk indicated procedures (CHIP) averting the risk of circulatory collapse and of adverse events in long lasting and/or complicated procedures. This review article aims to report the key factors to define CHIP, to summarize the available pLVAD which have CE mark for temporary mechanical LV support and to discuss the rationale of their use in this subset of patients. Based on the expertise of the Italian Society of Interventional Cardiology working group, with the endorsement from Spanish and Portuguese Society of Interventional Cardiology working groups, it will provide several practical suggestions in regards to the use of pLVAD in different clinical CHIP scenarios., (Copyright © 2019. Published by Elsevier B.V.)

Medical malpractice claims can be analysed to gain insights aimed at improving quality of care. However, using medical malpractice claims in medical research raises epistemological and methodological concerns related to certain features of the litigation process. Medical research should therefore approach medical malpractice claims with caution. Taking one recent study as a an example, this article insists on three areas of concern: (a) the quantity of legal materials available for analysis; (b) the content of the legal materials available for analysis; and (c) the ways in which the content of the legal materials should be analysed and the types of inferences that it can support. The article concludes with general recommendations for future medical research that would incorporate medical malpractice claims. These recommendations centre around recognizing the qualitative dimension of legal reasoning., (© 2019 John Wiley & Sons, Ltd.)

Objective: To assess the completeness of obstetric referral letters/notes at the district level of healthcare., Design: An implementation research within three districts in Greater Accra region using mixed methods. During baseline and intervention phases, referral processes for all obstetric referrals from lower level facilities seen at the district hospitals were documented including indications for referrals, availability and completeness of referral notes/forms. An assessment of before and after intervention availability and completeness of referral forms was carried out. Focus group discussions, non-participant observations and in-depth interviews with health workers and pregnant women were conducted for qualitative data., Setting: Three (3) districts in the Greater Accra region of Ghana., Participants: Pregnant women referred from lower levels of care to and seen at the district hospital, health workers within the three districts and pregnant women attending antenatal clinic in the district and their family members or spouses., Intervention: An enhanced interfacility referral communication system consisting of training, provision of communication tools for facilities, formation of hospital referral teams and strengthening feedback mechanisms., Outcome: Completeness of obstetric referral letters/notes., Results: Proportion of obstetric referrals with referral notes improved from 27.2% to 44.3% from the baseline to intervention period. Mean completeness (95% CI) of all forms was 71.3% (64.1% to 78.5%) for the study period, improving from 70.7% (60.4% to 80.9%) to 71.9% (61.1% to 82.7%) from baseline to intervention periods. Health workers reported they do not always provide referral notes and that most referral notes are not completely filled due to various reasons., Conclusions: Most obstetric referrals did not have referral notes. The few notes provided were not completely filled. Interventions such as training of health workers, regular review of referral processes and use of electronic records can help improve both the provision of and completeness of the referral notes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

The medical expert witness testimony is a key moment in the pathway of patient complaints as well as in the line of defense of the defendant-physician. For the defendant, it is a difficult time, often experienced as humiliating, because his or her competences are questioned, appraised and discussed in public. However, the defendant must perceive and use this encounter as an opportunity to express his/her viewpoint on the medical accident. This article provides the principal juridical rules that govern the medical expert witness testimony that must be known, as well as some practical advice on how the medical expert witness testimony evolves and how to protect oneself from the complaints, In order to enable the defendant to best prepare for this confrontation between the involved parties., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Direct eyewitness identification is widely used, but prone to error. We tested the validity of indirect eyewitness identification decisions using the reaction time-based concealed information test (CIT) for assessing cooperative eyewitnesses' face memory as an alternative to traditional lineup procedures. In a series of five experiments, a total of 401 mock eyewitnesses watched one of 11 different stimulus events that depicted a breach of law. Eyewitness identifications in the CIT were derived from longer reaction times as compared to well-matched foil faces not encountered before. Across the five experiments, the weighted mean effect size d was 0.14 (95% CI 0.08-0.19). The reaction time-based CIT seems unsuited for testing cooperative eyewitnesses' memory for faces. The careful matching of the faces required for a fair lineup or the lack of intent to deceive may have hampered the diagnosticity of the reaction time-based CIT.

Background: Clear guidance for successive antidepressant pharmacological treatments for non-responders in major depression is not well established., Method: Based on the RAND/UCLA Appropriateness Method, the French Association for Biological Psychiatry and Neuropsychopharmacology and the fondation FondaMental developed expert consensus guidelines for the management of treatment-resistant depression. The expert guidelines combine scientific evidence and expert clinicians' opinions to produce recommendations for treatment-resistant depression. A written survey comprising 118 questions related to highly-detailed clinical presentations was completed on a risk-benefit scale ranging from 0 to 9 by 36 psychiatrist experts in the field of major depression and its treatments. Key-recommendations are provided by the scientific committee after data analysis and interpretation of the results of the survey., Results: The scope of these guidelines encompasses the assessment of pharmacological resistance and situations at risk of resistance, as well as the pharmacological and psychological strategies in major depression., Conclusion: The expert consensus guidelines will contribute to facilitate treatment decisions for clinicians involved in the daily assessment and management of treatment-resistant depression across a number of common and complex clinical situations.

Despite major improvements in transcatheter aortic valve replacement (TAVR) periprocedural complications in recent years, the occurrence of conduction disturbances has not decreased over time and remains the most frequent complication of the procedure. Additionally, there has been an important lack of consensus on the management of these complications, which has indeed translated into a high degree of uncertainty regarding the most appropriate treatment of a large proportion of such patients along with major differences between centers and studies in pacemaker rates post-TAVR. There is therefore an urgent need for a uniform strategy regarding the management of conduction disturbances after TAVR. The present expert consensus scientific panel document has been formulated by a multidisciplinary group of interventional cardiologists, electrophysiologists, and cardiac surgeons as an initial attempt to provide a guide for the management of conduction disturbances after TAVR based on the best available data and group expertise., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)