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.

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.

Extranodal B-cell lymphoma in the urinary bladder with cytological evidence of concurrent involvement of the gall bladder in a cat

A 15-year-old domestic shorthair cat was presented with severe haematuria, stranguria, anorexia and lethargy of 10 days' duration. Physical examination revealed a large painful urinary bladder and pain in the cranial abdomen. Abdominal ultrasound revealed severe generalised mural thickening of both the gall bladder and the urinary bladder. Lymphoma was diagnosed on cytology of urine sediment and fine-needle aspirates of the gall bladder. Despite a transitory clinical improvement and partial remission following chemotherapy, the cat was euthanased six weeks after initial presentation due to recurrent clinical signs. Post-mortem examination confirmed a B-cell lymphoma in the urinary bladder. This report is the first description of gall bladder and bladder lymphoma in a cat.

Evidence for Concurrent Effects of Exposure to Environmental Cadmium and Lead on Hepatic CYP2A6 Phenotype and Renal Function Biomarkers in Non Smokers

We examined the interrelationships between phenotype of hepatic cytochrome P450 2A6 (CYP2A6), nephropathy, and exposure to cadmium and lead in a group of 118 healthy Thai men and women who had never smoked. Their urinary Cd excretion ranged from 0.05 to 2.36 mug/g creatinine, whereas their urinary Pb excretion ranged from 0.1 to 12 mug/g creatinine. Average age and Cd burden of women and men did not differ. Women, however, on average showed a 46% higher urinary Pb excretion (p < 0.001) and lower zinc status, suggested by lower average serum Zn and urinary Zn excretion compared with those in men. Cd-linked nephropathy was detected in both men and women. However, Pb-linked nephropathy was seen only in women, possibly because of higher Pb burden coupled with lower protective factors, notably of Zn (P < 0.001), in women compared with men. In men, Pb burden showed a negative association with CYP2A6 activity (adjusted beta = -0.29, p = 0.003), whereas Cd burden showed a positive association with CYP2A6 activity (adjusted beta = 0.38, p = 0.001), suggesting opposing effects of Cd and Pb on hepatic CYP2A6 phenotype. The weaker correlation between Cd burden CYP2A6 activity in women despite similarity in Cd burden between men and women is consistent with opposing effects of Pb and Cd on hepatic CYP2A6 phenotypic expression. A positive correlation between Cd-linked nephropathy (urinary N-acetyl-beta-D-glucosaminidase excretion) and CYP2A6 activity in men (r = 0.39, p = 0.002) and women (r = 0.37, p = 0.001) suggests that Cd induction of hepatic CYP2A6 expression and Cd-linked nephropathy occurred simultaneously.

The acquisition of an artificial logographic script and bilingual working memory : Evidence for L1-specific orthographic processing skills transfer in Chinese-English bilinguals

Studies of orthographic skills transfer between languages focus mostly on working memory (WM) ability in alphabetic first language (L1) speakers when learning another, often alphabetically congruent, language. We report two studies that, instead, explored the transferability of L1 orthographic processing skills in WM in logographic-L1 and alphabetic-L1 speakers. English-French bilingual and English monolingual (alphabetic-L1) speakers, and Chinese-English (logographic-L1) speakers, learned a set of artificial logographs and associated meanings (Study 1). The logographs were used in WM tasks with and without concurrent articulatory or visuo-spatial suppression. The logographic-L1 bilinguals were markedly less affected by articulatory suppression than alphabetic-L1 monolinguals (who did not differ from their bilingual peers). Bilinguals overall were less affected by spatial interference, reflecting superior phonological processing skills or, conceivably, greater executive control. A comparison of span sizes for meaningful and meaningless logographs (Study 2) replicated these findings. However, the logographic-L1 bilinguals’ spans in L1 were measurably greater than those of their alphabetic-L1 (bilingual and monolingual) peers; a finding unaccounted for by faster articulation rates or differences in general intelligence. The overall pattern of results suggests an advantage (possibly perceptual) for logographic-L1 speakers, over and above the bilingual advantage also seen elsewhere in third language (L3) acquisition.

A new model to study healing of a complex femur fracture with concurrent soft tissue injury in sheep

High energy bone fractures resulting from impact trauma are often accompanied by subcutaneous soft tissue injuries, even if the skin remains intact. There is evidence that such closed soft tissue injuries affect the healing of bone fractures, and vice versa. Despite this knowledge, most impact trauma studies in animals have focussed on bone fractures or soft tissue trauma in isolation. However, given the simultaneous impact on both tissues a better understanding of the interaction between these two injuries is necessary to optimise clinical treatment. The aim of this study was therefore to develop a new experimental model and characterise, for the first time, the healing of a complex fracture with concurrent closed soft tissue trauma in sheep. A pendulum impact device was designed to deliver a defined and standardised impact to the distal thigh of sheep, causing a reproducible contusion injury to the subcutaneous soft tissues. In a subsequent procedure, a reproducible femoral butterfly fracture (AO C3-type) was created at the sheep’s femur, which was initially stabilised for 5 days by an external fixator construct to allow for soft tissue swelling to recede, and ultimately in a bridging construct using locking plates. The combined injuries were applied to twelve sheep and the healing observed for four or eight weeks (six animals per group) until sacrifice. The pendulum impact led to a moderate to severe circumferential soft tissue injury with significant bruising, haematomas and partial muscle disruptions. Posttraumatic measurements showed elevated intra-compartmental pressure and circulatory tissue breakdown markers, with recovery to normal, pre-injury values within four days. Clinically, no neurovascular deficiencies were observed. Bi-weekly radiological analysis of the healing fractures showed progressive callus healing over time, with the average number of callus bridges increasing from 0.4 at two weeks to 4.2 at eight weeks. Biomechanical testing after sacrifice showed increasing torsional stiffness between four and eight weeks healing time from 10% to 100%, and increasing ultimate torsional strength from 10% to 64% (relative to the contralateral control limb). Our results demonstrate the robust healing of a complex femur fracture in the presence of a severe soft tissue contusion injury in sheep and demonstrate the establishment of a clinically relevant experimental model, for research aimed at improving the treatment of bone fractures accompanied by closed soft tissue injuries.

The requirements for Ca2+, protein phosphorylation and concurrent protein synthesis for zeatin signaling of acidic chitinase transcript accumulation in Cucumis sativus L

We have previously reported that both Ca2+ and staurosporine-sensitive protein kinase(s) are involved in the cytokinin zeatin induction of cucumber chitinase activity and its protein content (Barwe et al. 2001). To further characterize signal transduction events involved in this cytokinin induction of chitinase gene expression, Northern hybridizations of total RNAs prepared from excised, dark-grown cucumber cotyledons treated with cytokinins and/or various agonists and antagonists of signal transduction components, were carried out using a cucumber acidic chitinase (CACHT) cDNA probe (Metraux et al. 1989). CACHT mRNA increased by approximately 5- to 6-fold in response to exogenous zeatin (Z), zeatin riboside (ZR), and benzyladenine (BA) treatment, but failed to accumulate in response to kinetin (K). Among the cytokinins tested, Z was most effective. The Z-induced accumulation of CACHT mRNA was inhibited by a plasma membrane Ca2+ channel blocker verapamil. Treatment of cotyledons with exogenous CaCl2 and calcium ionophore A23187 in the presence and absence of cytokinin enhanced CACHT mRNA accumulation. These two observations suggest the participation of extracellular calcium in signaling Z-induction. Furthermore, the presence of staurosporine (an inhibitor of protein kinase) in Z treatment reduced CACHT mRNA, suggesting the involvement of phosphorylation of one or more cellular proteins. In addition, we provide evidence that the Z-induction of CACHT mRNA is blocked by protein synthesis inhibitor cycloheximide treatment. Taken together, these results suggest that Ca2+ influx from extracellular space, protein phosphorylation, and concurrent protein synthesis events participate in cytokinin signaling during Z-induced CACHT transcript accumulation.

Increases in the relative abundance of mid-trophic level fishes concurrent with declines in apex predators in the subtropical North Pacific, 1996–2006

Catch rates for the 13 most abundant species caught in the deep-set Hawaii-based longline fishery over the past decade (1996–2006) provide evidence of a change among the top North Pacific subtropical predators. Catch rates for apex predators such as blue shark (Prionace glauca), bigeye (Thunnus obesus) and albacore (Thunnus alalunga) tunas, shortbill spearfish (Tetrapturus angustirostris), and striped marlin (Tetrapturus audax) declined by 3% to 9% per year and catch rates for four midtrophic species, mahimahi (Coryphaena hippurus), sickle pomfret (Taractichthys steindachneri), escolar (Lepidocybium flavobrunneum), and snake mackerel (Gempylus serpens), increased by 6% to 18% per year. The mean trophic level of the catch for these 13 species declined 5%, from 3.85 to 3.66. A shift in the ecosystem to an increase in midtrophic-level, fast-growing and short-lived species is indicated by the decline in apex predators in the catch (from 70% to 40%) and the increase in species with production to biomass values of 1.0 or larger in the catch (from 20% to 40%). This altered ecosystem may exhibit more temporal variation in response to climate variability.

Beta-agonist- and prostaglandin E1-induced translocation of the beta-adrenergic receptor kinase: evidence that the kinase may act on multiple adenylate cyclase-coupled receptors.

beta-Adrenergic receptor kinase (beta-AR kinase) is a cytosolic enzyme that phosphorylates the beta-adrenergic receptor only when it is occupied by an agonist [Benovic, J. Strasser, R. H., Caron, M. G. & Lefkowitz, R. J. (1986) Proc. Natl. Acad. Sci. USA 83, 2797-2801.] It may be crucially involved in the processes that lead to homologous or agonist-specific desensitization of the receptor. Stimulation of DDT1MF-2 hamster smooth muscle cells or S49 mouse lymphoma cells with a beta-agonist leads to translocation of 80-90% of the beta-AR kinase activity from the cytosol to the plasma membrane. The translocation process is quite rapid, is concurrent with receptor phosphorylation, and precedes receptor desensitization and sequestration. It is also transient, since much of the activity returns to the cytosol as the receptors become sequestered. Stimulation of beta-AR kinase translocation is a receptor-mediated event, since the beta-antagonist propranolol blocks the effect of agonist. In the kin- mutant of the S49 cells (lacks cAMP-dependent protein kinase), prostaglandin E1, which provokes homologous desensitization of its own receptor, is at least as effective as isoproterenol in promoting beta-AR kinase translocation to the plasma membrane. However, in the DDT1MF-2 cells, which contain alpha 1-adrenergic receptors coupled to phosphatidylinositol turnover, the alpha 1-agonist phenylephrine is ineffective. These results suggest that the first step in homologous desensitization of the beta-adrenergic receptor may be an agonist-promoted translocation of beta-AR kinase from cytosol to plasma membrane and that beta-AR kinase may represent a more general adenylate cyclase-coupled receptor kinase that participates in regulating the function of many such receptors.

Task prioritization in aging: effects of sensory information on concurrent posture and memory performance

In older adults, cognitive resources play a key role in maintaining postural stability. In the present study, we evaluated whether increasing postural instability using sway referencing induces changes in resource allocation in dual-task performance leading older adults to prioritize the more age-salient posture task over a cognitive task. Young and older adults participated in the study which comprised two sessions. In the first session, three posture tasks (stable, sway reference visual, sway reference somatosensory) and a working memory task (n-back) were examined. In the second session, single- and dual-task performance of posture and memory were assessed. Postural stability improved with session. Participants were more unstable in the sway reference conditions, and pronounced age differences were observed in the somatosensory sway reference condition. In dual-task performance on the stable surface, older adults showed an almost 40% increase in instability compared to single-task. However, in the sway reference somatosensory condition, stability was the same in single- and dual-task performance, whereas pronounced (15%) costs emerged for cognition. These results show that during dual-tasking while standing on a stable surface, older adults have the flexibility to allow an increase in instability to accommodate cognitive task performance. However, when instability increases by means of compromising somatosensory information, levels of postural control are kept similar in single- and dual-task, by utilizing resources otherwise allocated to the cognitive task. This evidence emphasizes the flexible nature of resource allocation, developed over the life-span to compensate for age-related decline in sensorimotor and cognitive processing.

Asynchrony between the Greenland ice core chronology and the radiocarbon calibration curve? Evidence from Irish bogs

A significant cold event, deduced from the Greenland ice cores, took place between 8200 and 8000 cal. BP. Modeling of the event suggests that higher northern latitudes would have also experienced considerable decreases in precipitation and that Ireland would have witnessed one of the greatest depressions. However, no well-dated proxy record exists from the British Isles to test the model results. Here we present independent evidence for a phase of major pine recruitment on Irish bogs at around 8150 cal. BP. Dendrochronological dating of subfossil trees from three sites reveal synchronicity in germination across the region, indicative of a regional forcing, and allows for high-precision radiocarbon based dating. The inner-rings of 40% of all samples from the north of Ireland dating to the period 8500-7500 cal. BP fall within a 25-yr window. The concurrent colonization of pine on peatland is interpreted as drier conditions in the region and provides the first substantive proxy data in support of a significant hydrological change in the north of Ireland accompanying the 8.2 ka event. The dating uncertainties associated with the Irish pine record and the Greenland Ice Core Chronology 2005 (GICC05) do not allow for any overlap between the two. Our results indicate that the discrepancy could be an artifact of dating inaccuracy, and support a similar claim by Lohne et al. (2013) for the Younger Dryas boundaries. If real, this asynchrony will most likely have affected interpretations of previous proxy alignments.

Asynchrony in key Holocene chronologies: Evidence from Irish bog pines

The Greenland Ice Core Chronology 2005 (GICC05) and the radiocarbon calibration curve (IntCal) are the foremost time scales used in paleoclimatic and paleoenvironmental studies of the most recent 10 k.y. Due to varying and often insufficient dating resolution, opportunities to test the synchrony of these two influential chronologies are rare. Here we present evidence for a phase of major pine recruitment on Irish bogs at ca. 8160 yr B.P. Dendrochronological dating of subfossil trees from three sites reveals synchronicity in germination across the study area, indicative of a regional forcing. The concurrent colonization of pine on peatland is interpreted in terms of drier surface conditions and provides the first substantive proxy data in support of a significant hydroclimatic change in the north of Ireland accompanying the 8.2 ka climate cooling event. The date of pine establishment does not overlap with the GICC05 age range for the event, and possible lags between responses are unlikely to explain the full difference. In light of recent studies highlighting a possible offset in GICC05 and IntCal dates, the Irish pine record supports the notion of ice core dates being too early during the period of study. If the suggested discrepancy in timing is an artifact of chronological error, it is likely to have affected interpretations of previous proxy comparisons and alignments.

Best Practice for Providing Social Care and Support to People Living with Concurrent Sight Loss and Dementia: Professional Perspectives

Purpose-Approximately 100,000 people in the UK aged 75 and over have concurrent dementia and sight loss, but current understanding of their experiences, needs and preferences is limited. The purpose of this paper is to report on a research project that explored the provision of social care and support for older people with both conditions. Design/methodology/approach-The project was a collaboration between the universities of York, Worcester, Bournemouth and Cambridge, supported by the Thomas Pocklington Trust and the Housing and Dementia Research Consortium. Data for this paper were drawn from focus groups held in 2013 involving 47 professionals across the dementia, sight loss and housing sectors. Findings-Thematic analysis identified five main barriers to providing high-quality, cost-effective social care and support: time constraints; financial limitations; insufficient professional knowledge; a lack of joint working; and inconsistency of services. The requirements of dementia and sight loss often conflict, which can limit the usefulness of equipment, aids and adaptations. Support and information needs to address individual needs and preferences. Research limitations/implications-Unless professionals consider dementia and sight loss together, they are unlikely to think about the impact of both conditions and the potential of their own services to provide effective support for individuals and their informal carers. Failing to consider both conditions together can also limit the availability and accessibility of social care and support services. This paper is based on input from a small sample of self-selecting professionals across three geographical regions of England. More research is needed in this area. Practical implications-There are growing numbers of people living with concurrent dementia and sight loss, many of whom wish to remain living in their own homes. There is limited awareness of the experiences and needs of this group and limited provision of appropriate services aids/adaptations. A range of measures should be implemented in order to support independence and well-being for people living with both conditions and their family carers. These include increased awareness, improved assessment, more training and greater joint working. Social implications-People living with dementia or sight loss are at high risk of social isolation, increasingly so for those with both conditions. Services that take an inclusive approach to both conditions can provide crucial opportunities for social interaction. Extra care housing has the potential to provide a supportive, community-based environment that can help residents to maintain social contact. Originality/value-This paper adds much-needed evidence to the limited existing literature, and reflects the views of diverse professionals across housing, health and social care

Evidence for a widespread climatic anomaly at around 9.2 ka before present.

The 8.2 ka event was triggered by a meltwater pulse (MWP) into the North Atlantic and resultant reduction of the thermohaline circulation (THC). This event was preceded by a series of at least 14 MWPs; their impact on early Holocene climate has remained almost unknown. A set of high-quality paleoclimate records from across the Northern Hemisphere shows evidence for a widespread and significant climatic anomaly at ∼9.2 ka B.P. This event has climatic anomaly patterns very similar to the 8.2 ka B.P. event, cooling occurred at high latitudes and midlatitudes and drying took place in the northern tropics, and is concurrent with an MWP of considerable volume (∼8100 km3). As the 9.2 ka MWP occurs at a time of enhanced baseline freshwater flow into the North Atlantic, this MWP may have been, despite its relatively small volume, sufficient to weaken THC and to induce the observed climate anomaly pattern.

No evidence for mirror system dysfunction in schizophrenia from a multimodal TMS/EEG study

Dysfunctional mirror neuron systems have been proposed to contribute to the social cognitive deficits observed in schizophrenia. A few studies have explored mirror systems in schizophrenia using various techniques such as TMS (levels of motor resonance) or EEG (levels of mu suppression), with mixed results. This study aimed to use a novel multimodal approach (i.e. concurrent TMS and EEG) to further investigate mirror systems and social cognition in schizophrenia. Nineteen individuals with schizophrenia or schizoaffective disorder and 19 healthy controls participated. Single-pulse TMS was applied to M1 during the observation of hand movements designed to elicit mirror system activity. Single EEG electrodes (C3, CZ, C4) recorded brain activity. Participants also completed facial affect recognition and theory of mind tasks. The schizophrenia group showed significant deficits in facial affect recognition and higher level theory of mind compared to healthy controls. A significant positive relationship was revealed between mu suppression and motor resonance for the overall sample, indicating concurrent validity of these measures. Levels of mu suppression and motor resonance were not significantly different between groups. These findings indicate that in stable outpatients with schizophrenia, mirror system functioning is intact, and therefore their social cognitive difficulties may be caused by alternative pathophysiology.