Adapting to concurrent expert evidence in medical litigation

In medical negligence litigation expert evidence has long played a dominant role. The trend towards the use of concurrent expert evidence is now well underway. However, for the lawyers and the doctors involved, the pathway is not yet familiar. Disputes have frequently arisen in the context of pre-hearing expert conclaves, given the adversarial nature of litigation and perhaps fuelled by fears of a less transparent process at this increasingly important stage. This article explains the concurrent expert evidence framework and examines areas of common dispute both in the conclaves and at trial, with a view to providing assistance to legal practitioners working in this area and the medical practitioners called upon to provide expert evidence in such litigation.

Progress in the genetics of ankylosing spondylitis

Ankylosing spondylitis (AS) is a common, highly heritable, inflammatory arthropathy. In addition to being strongly associated with HLA-B27, a further 13 genes have been robustly associated with the disease. These genes highlight the involvement of the IL-23 pathway in disease pathogenesis, and indicate overlaps between the pathogenesis of AS, and of inflammatory bowel disease. Genetic associations in B27-positive and -negative disease are similar, with the main exception of association with ERAP1, which is restricted in association to B27-positive cases. This restriction, and the known function of ERAP1 in peptide trimming prior to HLA Class I presentation, indicates that HLA-B27 is likely to operate in AS by a mechanism involving aberrant peptide handling. These advances point to several potential novel therapeutic approaches in AS.

Parenting and the behavior problems of young children with an intellectual disability: Concurrent and longitudinal relationships in a population-based study

We examined parenting behaviors, and their association with concurrent and later child behavior problems. Children with an intellectual disability (ID) were identified from a UK birth cohort (N  =  516 at age 5). Compared to parents of children without an ID, parents of children with an ID used discipline less frequently, but reported a more negative relationship with their child. Among children with an ID, discipline, and home atmosphere had no long-term association with behavior problems, whereas relationship quality did: closer relationships were associated with fewer concurrent and later child behavior problems. Increased parent-child conflict was associated with greater concurrent and later behavior problems. Parenting programs in ID could target parent-child relationship quality as a potential mediator of behavioral improvements in children.

Interaction between ERAP1 and HLA-B27 in ankylosing spondylitis implicates peptide handling in the mechanism for HLA-B27 in disease susceptibility

Ankylosing spondylitis is a common form of inflammatory arthritis predominantly affecting the spine and pelvis that occurs in approximately 5 out of 1,000 adults of European descent. Here we report the identification of three variants in the RUNX3, LTBR-TNFRSF1A and IL12B regions convincingly associated with ankylosing spondylitis (P < 5 × 10-8 in the combined discovery and replication datasets) and a further four loci at PTGER4, TBKBP1, ANTXR2 and CARD9 that show strong association across all our datasets (P < 5 × 10-6 overall, with support in each of the three datasets studied). We also show that polymorphisms of ERAP1, which encodes an endoplasmic reticulum aminopeptidase involved in peptide trimming before HLA class I presentation, only affect ankylosing spondylitis risk in HLA-B27-positive individuals. These findings provide strong evidence that HLA-B27 operates in ankylosing spondylitis through a mechanism involving aberrant processing of antigenic peptides.

A Proposal for Concurrent Estimation of Static and Dynamic Nonlinearity of ADC

Despite great advances in very large scale integrated-circuit design and manufacturing, performance of even the best available high-speed, high-resolution analog-to-digital converter (ADC) is known to deteriorate while acquiring fast-rising, high-frequency, and nonrepetitive waveforms. Waveform digitizers (ADCs) used in high-voltage impulse recordings and measurements are invariably subjected to such waveforms. Errors resulting from a lowered ADC performance can be unacceptably high, especially when higher accuracies have to be achieved (e.g., when part of a reference measuring system). Static and dynamic nonlinearities (estimated independently) are vital indices for evaluating performance and suitability of ADCs to be used in such environments. Typically, the estimation of static nonlinearity involves 10-12 h of time or more (for a 12-b ADC) and the acquisition of millions of samples at high input frequencies for dynamic characterization. ADCs with even higher resolution and faster sampling speeds will soon become available. So, there is a need to reduce testing time for evaluating these parameters. This paper proposes a novel and time-efficient method for the simultaneous estimation of static and dynamic nonlinearity from a single test. This is achieved by conceiving a test signal, comprised of a high-frequency sinusoid (which addresses dynamic assessment) modulated by a low-frequency ramp (relevant to the static part). Details of implementation and results on two digitizers are presented and compared with nonlinearities determined by the existing standardized approaches. Good agreement in results and time savings achievable indicates its suitability.

A Proposal for Concurrent Estimation of Static and Dynamic Nonlinearity of ADC

Despite great advances in very large scale integrated-circuit design and manufacturing, performance of even the best available high-speed, high-resolution analog-to-digital converter (ADC) is known to deteriorate while acquiring fast-rising, high-frequency, and nonrepetitive waveforms. Waveform digitizers (ADCs) used in high-voltage impulse recordings and measurements are invariably subjected to such waveforms. Errors resulting from a lowered ADC performance can be unacceptably high, especially when higher accuracies have to be achieved (e.g., when part of a reference measuring system). Static and dynamic nonlinearities (estimated independently) are vital indices for evaluating performance and suitability of ADCs to be used in such environments. Typically, the estimation of static nonlinearity involves 10-12 h of time or more (for a 12-b ADC) and the acquisition of millions of samples at high input frequencies for dynamic characterization. ADCs with even higher resolution and faster sampling speeds will soon become available. So, there is a need to reduce testing time for evaluating these parameters. This paper proposes a novel and time-efficient method for the simultaneous estimation of static and dynamic nonlinearity from a single test. This is achieved by conceiving a test signal, comprised of a high-frequency sinusoid (which addresses dynamic assessment) modulated by a low-frequency ramp (relevant to the static part). Details of implementation and results on two digitizers are presented and compared with nonlinearities determined by the existing standardized approaches. Good agreement in results and time savings achievable indicates its suitability.

Handling of Two Tropical Australian Sharks to Improve Quality and to Identify the Cause of Tough Texture

Sharks caught in tropical Australian waters occasionally exhibit tough texture. Two species of Carcharinid shark, originally known as the sorrah shark (Carcharinus sorrah) and the black spot shark (Carcharinus tilstoni), compose the majority of the catch. Experiments were conducted to identify the cause of tough texture and to improve the overall quality of the catch. The possibility that a cold shock reaction may occur was investigated by observing the contraction of fillets under a range of temperature conditions before freezing. The effect of on-board handling practices were evaluated using frozen shark fillets, which had been stored prior to freezing in refrigerated seawater at different rigor stages, temperatures and times as trunks. Fillets were analyzed for nucleotides, lactate, thaw pH, sarcomere length and raw and cooked shear force values. The existence of thaw rigor was also investigated. There was little difference in the texture between the individual strips of a fillet exposed to different temperatures but there were significant differences between individual sharks. A cold shock reaction could not be demonstrated in these species. The main influences on texture were of biological origin. The species, sex and size were found to have significant links with texture of fillets. The quality of the fillets deteriorated quicker during the warmer season and were at their worst if the trunks were kept on deck till post-rigor or held in 15 degree C refrigerated seawater before freezing

Bond graph toolbox for handling complex variable

Bond graph is an apt modelling tool for any system working across multiple energy domains. Power electronics system modelling is usually the study of the interplay of energy in the domains of electrical, mechanical, magnetic and thermal. The usefulness of bond graph modelling in power electronic field has been realised by researchers. Consequently in the last couple of decades, there has been a steadily increasing effort in developing simulation tools for bond graph modelling that are specially suited for power electronic study. For modelling rotating magnetic fields in electromagnetic machine models, a support for vector variables is essential. Unfortunately, all bond graph simulation tools presently provide support only for scalar variables. We propose an approach to provide complex variable and vector support to bond graph such that it will enable modelling of polyphase electromagnetic and spatial vector systems. We also introduced a rotary gyrator element and use it along with the switched junction for developing the complex/vector variable's toolbox. This approach is implemented by developing a complex S-function tool box in Simulink inside a MATLAB environment This choice has been made so as to synthesise the speed of S-function, the user friendliness of Simulink and the popularity of MATLAB.

Predicting survival of western rock lobsters Panulirus cygnus using discriminant analysis of hemolymph parameters taken immediately following simulated handling treatments

Instances of morbidity amongst rock lobsters (Panulirus cygnus) arriving at factories in Western Australia (WA) have been attributed to stress during post-harvest handling. This study used discriminant analysis to determine whether physiological correlates of stress following a period of simulated post-harvest handling had any validity as predictors of future rejection or morbidity of western rock lobsters. Groups of 230 western rock lobsters were stored for 6 h in five environments (submerged/flowing sea water, submerged/re-circulating sea water, humid air, flowing sea water spray, and re-circulated sea water spray). The experiment was conducted in late spring (ambient sea water 22°C), and repeated again in early autumn (ambient sea water 26°C). After 6 h treatment, each lobster was graded for acceptability for live export, numbered, and its hemolymph was sampled. The samples were analysed for a number of physiological and health status parameters. The lobsters were then stored for a week in tanks in the live lobster factory to record mortality. The mortality of lobsters in the factory was associated with earlier deviations in hemolymph parameters as they emerged from the storage treatments. Discriminant analysis (DA) of the hemolymph assays enabled the fate of 80-90% of the lobsters to be correctly categorised within each experiment. However, functions derived from one experiment were less accurate at predicting mortality when applied to the other experiments. One of the reasons for this was the higher mortality and the more severe patho-physiological changes observed in lobsters stored in humid air or sprays at the higher temperature. The analysis identified lactate accumulation during emersion and associated physiological and hemocyte-related effects as a major correlate of mortality. Reducing these deviations, for example by submerged transport, is expected to ensure high levels of survival. None of the indicators tested predicted mortality with total accuracy. The simplest and most accurate means of comparing emersed treatments was to count the mortality afterwards.

Value-adding Australian sardines: Factors affecting rates of deterioration in sardine (Sardinops sagax) quality during post-harvest handling

Deficiencies in sardine post-harvest handling methods were seen as major impediments to development of a value-adding sector supplying Australian bait and human consumption markets. Factors affecting sardine deterioration rates in the immediate post-harvest period were investigated and recommendations made for alternative handling procedures to optimise sardine quality. Net to factory sampling showed that post-mortem autolysis was probably caused by digestive enzyme activity contributing to the observed temporal increase in sardine Quality Index. Belly burst was not an issue. Sardine quality could be maintained by reducing tank loading, and rapid temperature reduction using dedicated, on-board value-adding tanks. Fish should be iced between the jetty and the processing factory, and transport bins chilled using an efficient cooling medium such as flow ice.

Quality of handling and holding yard environment, and beef cattle temperament: 1. Relationships with flight speed and fear of humans.

Numerous tests have been used to measure beef cattle temperament, but limited research has addressed the relationship between such tests and whether temperament can be modified. One-hundred-and-forty-four steers were given one of three human handling and yarding experiences on six occasions during a 12-month grazing period post-weaning (backgrounding): Good handling/yarding, Poor handling/yarding and Minimal handling/yarding. At the end of this phase the cattle were lot-fed for 78 days, with no handling/yarding treatments imposed, before being transported for commercial slaughter. Temperament was assessed at the start of the experiment, during backgrounding and lot-feeding by flight speed (FS) and a fear of humans test, which measured the proximity to a stimulus person (zone average; ZA), the closest approach to the person (CA) and the amount the cattle moved around the test arena (total transitions; TT). During backgrounding, FS decreased for all treatments and at the end of backgrounding there was no difference between them. The rate of decline, however, was greatest in the Good group, smallest in the Minimal group with the Poor intermediate. In contrast, ZA was affected by treatment, with a greater reduction for the Good group than the others (P = 0.012). During lot-feeding, treatment did not affect FS, but all groups showed a decrease in ZA, with the greatest change in the Poor group, the least in the Good and the Minimal intermediate (P = 0.052). CA was positively correlated with ZA (r = 0.18 to 0.66) and negatively with TT (r = -0.180 to -0.659). FS was consistently correlated with TT only (r = 0.17 to 0.49). These findings suggest that FS and TT measure a similar characteristic, as do ZA and CA, but that these characteristics are different from one another, indicating that temperament is not a unitary trait, but has different facets. FS and TT measure one facet that we suggest is general agitation, whilst ZA and CA measure fear of people. Thus, the cattle became less agitated during backgrounding, but the effect was not permanently influenced by the quantity and quality of handling/yarding. However, Good handling/yarding reduced fearfulness of people. Fear of people was also reduced during lot-feeding, probably as a consequence of frequent exposure to humans in a situation that was neutral or positive for the cattle.

Theoretical Maximum Limits on Power-Handling Capacity of HVDC Cables

In the case of an ac cable, power transmission is limited by the length of the cable due to the capacitive reactive current component. It is well known that high-voltage direct current (HVDC) cables do not have such limitations. However, insulation-related thermal problems pose a limitation on the power capability of HVDC cables. The author presents a viable theoretical development, a logical extension to Whitehead's theory on thermal limitations of the insulation. The computation of the maximum power-carrying capability of HVDC cables subject to limits on the maximum operable temperature of the insulation is presented. The limitation on the power-carrying capability is closely associated with the electrothermal insulation failure. The effect of environmental interaction by way of external thermal resistance, an important aspect, is also considered in the formulations. The Lagrange multiplier method has been used to handle the ensuing optimization problem. The theory is based on an accepted theory of thermal breakdown in insulation and is an important and a coherent extension of great significance.

Equipping the mud crab industry with innovative skills through extension of best practice handling

Maximum adoption throughout the supply-chain of research findings that attained premium quality for live mud crabs.

Feasibility of a stepped wedge cluster RCT and concurrent observational sub-study to evaluate the effects of modified ward night lighting on inpatient fall rates and sleep quality: A protocol for a pilot trial

Background: Falls among hospitalised patients impose a considerable burden on health systems globally and prevention is a priority. Some patient-level interventions have been effective in reducing falls, but others have not. An alternative and promising approach to reducing inpatient falls is through the modification of the hospital physical environment and the night lighting of hospital wards is a leading candidate for investigation. In this pilot trial, we will determine the feasibility of conducting a main trial to evaluate the effects of modified night lighting on inpatient ward level fall rates. We will test also the feasibility of collecting novel forms of patient level data through a concurrent observational sub-study. Methods/design: A stepped wedge, cluster randomised controlled trial will be conducted in six inpatient wards over 14 months in a metropolitan teaching hospital in Brisbane (Australia). The intervention will consist of supplementary night lighting installed across all patient rooms within study wards. The planned placement of luminaires, configurations and spectral characteristics are based on prior published research and pre-trial testing and modification. We will collect data on rates of falls on study wards (falls per 1000 patient days), the proportion of patients who fall once or more, and average length of stay. We will recruit two patients per ward per month to a concurrent observational sub-study aimed at understanding potential impacts on a range of patient sleep and mobility behaviour. The effect on the environment will be monitored with sensors to detect variation in light levels and night-time room activity. We will also collect data on possible patient-level confounders including demographics, pre-admission sleep quality, reported vision, hearing impairment and functional status. Discussion: This pragmatic pilot trial will assess the feasibility of conducting a main trial to investigate the effects of modified night lighting on inpatient fall rates using several new methods previously untested in the context of environmental modifications and patient safety. Pilot data collected through both parts of the trial will be utilised to inform sample size calculations, trial design and final data collection methods for a subsequent main trial.

Conclaves and concurrent expert evidence: A positive development in Australian legal practice?

Many Australian courts now prefer pre-hearing meetings of experts (conclaves) being convened to prepare joint reports to identify areas of agreement and disagreement, followed by concurrent expert evidence at trial. This contrasts to the traditional approach where experts did not meet before trial and did not give evidence together. Most judges, lawyers and expert witnesses favour this as a positive development in Australian legal practice, at least for civil disputes. This new approach impacts medical practitioners who are called upon to give expert evidence, or who are parties to disputes before the courts. Arguably, it is too soon to tell whether the relative lack of transparency at the conclave stage will give rise to difficulties in the coronial, disciplinary and criminal arenas.