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A special issue of International Journal of Environmental Research and Public Health (ISSN 1660-4601). This special issue belongs to the section "Infectious Disease Epidemiology".

Deadline for manuscript submissions: closed (30 June 2021) | Viewed by 44375

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Special Issue Editors

Dr. Michael D. Freeman

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1. Faculty of Health, Medicine and Life Sciences, Maastricht University, 6211 LK Maastricht, The Netherlands
2. Faculty of Forensic and Legal Medicine, Royal College of Physicians, London NW1 4LE, UK
3. Department of Psychiatry, School of Medicine, Oregon Health & Science University, Portland, OR 97035, USA
Interests: forensic medicine; forensic epidemiology; injury epidemiology/causation; injury biomechanics
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Prof. Dr. Maurice Zeegers

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Guest Editor

Faculty of Health, Medicine and Life Sciences, Maastricht University, 6211 LK Maastricht, The Netherlands
Interests: forensic epidemiology; epidemiologic methods
Special Issues, Collections and Topics in MDPI journals

Prof. Dr. Henry Otgaar

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Guest Editor

Section Forensic Psychology, Clinical Psychological Science, Departments, Faculty of Psychology and Neuroscience, Maastricht University, NL-6200 MD Maastricht, The Netherlands
Interests: legal psychology; forensic psychology

Special Issue Information

Dear Colleagues,

Over the past 50 years judicial courts around the world have increasingly relied on epidemiologic evidence as a basis for evaluating the causal relationship between an exposure and an injury or disease outcome. The use of epidemiologic legal evidence has evolved over the years; initially it was used primarily for establishing general (population) causal relationships, but not for specific (individual) causation, as this was traditionally the domain of a clinician who had also diagnosed the illness or injury in the individual. More recently, courts have gained better understanding that diagnosis and causation are different processes, and unlike the former, the latter cannot be observed, but rather must be inferred from a comparison of risks (i.e. the risk of the injury/disease given the exposure versus the hypothetical risk of the injury/disease in the absence of the exposure). This understanding has led to the development and expansion of the field of forensic epidemiology (FE).

Most broadly, FE can be used to describe any application of epidemiology to a civil, criminal, or other judicial matter. More specifically, the discipline of forensic epidemiology (FE) consists of a hybrid of principles and practices common to both forensic medicine (i.e. the intersection of law and medicine) and epidemiology. The most frequent application of FE is directed at assessing and quantifying complex or disputed causal relationships arising in a civil or criminal matter. In some cases a FE analysis may require the interpretation and extrapolation of the relative risks (RR) or odds ratios (OR) from observational studies to a set of specific circumstances, and in others it might require the ad hoc statistical analysis of epidemiologic data to assess a unique and previously unexamined medicolegal question, resulting in a case specific comparative risk ratio (CRR). Other applications include the assessment of the accuracy of clinical diagnostic tests, or the reliability of certain types of evidence, used to assess a pivotal legal question (such as the degree to which certain injury patterns indicate a particular cause, mechanism, or intent of injury), and survival analysis customized to a case specific set of predictive factors. The ultimate purpose of an FE analysis is to provide a systematic, reliable, and transparent means of addressing relevant medicolegal questions of a probabilistic nature, suitable for presentation to a legal fact finder (judge or jury) in a civil or criminal matter.

This Special Issue seeks papers on all forensic applications of epidemiology, including observational studies directed at a medicolegal issue, systematic or scientific reviews, and case series demonstrating applied methods, among others. We are hopeful that this Special Issue will trigger increased interest from a broad audience for the wide variety of applications within forensic epidemiology.

Prof. Dr. Michael D. Freeman
Prof. Dr. Maurice Zeegers
Prof. Dr. Henry Otgaar
Guest Editors

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Keywords

forensic epidemiology
biostatistics
negligence
homicide
abuse
injury patterns
injury biomechanics
forensic psychology
life expectancy

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Published Papers (8 papers)

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Research

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14 pages, 2662 KiB

Open AccessArticle

Principles and Methods for Evidence-Based Quantification of the Effect of Seat Belt Non-Use in Crash-Related Litigation

by Michael D. Freeman

Int. J. Environ. Res. Public Health 2021, 18(18), 9455; https://doi.org/10.3390/ijerph18189455 - 8 Sep 2021

Cited by 1 | Viewed by 2615

Abstract

Traffic crashes are a common cause of injury and death, and often result from the negligent actions of an inattentive, speeding, or impaired driver. In such cases, a civil legal action may be brought by an injured claimant for compensation for injuries resulting from a crash. Crash-related litigation is defended on various theories, one of which is to raise the issue of contributory negligence when the claimant was not using an available seat belt at the time of the crash, based on the assertion that the claimed injuries would have been avoided or minimized to some degree if the claimant had been restrained. At present, there are no published standards or systematic approach for assessing and quantifying the contribution of seat belt non-use to the cause of a claimant’s specific injury. A reliable medicolegal analysis that addresses whether contributory negligence can be proven in a specific case requires a multidisciplinary approach: First, the nature and severity of the crash must be reconstructed as it affected the vehicle kinetics (engineering) and in turn affected the kinematics of the occupant (biomechanics), next, the injuries must be described and scaled for severity (medicine/pathology), and finally, the risk of the known injuries given the actual circumstances of the crash and occupant (i.e., unbelted) are compared to the risk of the same injuries, and the same crash circumstances, but in the hypothetical scenario in which the claimant is belted. In the present discussion, methods for analyzing the presence and quantifying the degree of contributory negligence for seat belt non-use, suitable for presentation in a medicolegal setting, are described and illustrated with an example from the author’s personal case inventory. A detailed reconstruction of the crash is described, along with the associated occupant kinematics, and the resulting observed injuries. The injuries are then categorized by their anatomical location, type, and severity using Abbreviated Injury Scale designations. Quantification of the injury risk for the actual (unbelted) vs. hypothetical (belted) scenario is based on case-specific analysis of data accessed from a US national crash injury database The difference in risk for the two exposure scenarios can be quantified in terms of either relative risk (a risk ratio) or attributable risk (a risk proportion), with the goal to determine whether the analysis meets the threshold of a relative risk of >2.0, or an attributable risk of 50%, in order to meet the “more probable than not” standard typically required by courts. As a final step in a reliable analysis that exceeds the legal threshold for relevant evidence, the absolute increase in risk is used to quantify the degree to which the claimant’s seat belt non-use contributed to the likelihood of their injuries. Full article

(This article belongs to the Special Issue Forensic Epidemiology)

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13 pages, 1643 KiB

Open AccessArticle

Dying “from” or “with” COVID-19 during the Pandemic: Medico-Legal Issues According to a Population Perspective

by Fabio De-Giorgio, Vincenzo M. Grassi, Eva Bergamin, Alessandro Cina, Franca Del Nonno, Daniele Colombo, Roberta Nardacci, Laura Falasca, Celeste Conte, Ernesto d’Aloja, Gianfranco Damiani and Giuseppe Vetrugno

Int. J. Environ. Res. Public Health 2021, 18(16), 8851; https://doi.org/10.3390/ijerph18168851 - 22 Aug 2021

Cited by 17 | Viewed by 3168

Abstract

There is still a lack of knowledge concerning the pathophysiology of death among COVID-19-deceased patients, and the question of whether a patient has died with or due to COVID-19 is still very much debated. In Italy, all deaths of patients who tested positive for SARS-CoV-2 are defined as COVID-19-related, without considering pre-existing diseases that may either contribute to or even cause death. Our study included nine subjects from two different nursing homes (Cases 1–4, Group A; Cases 5–9, Group B). The latter included patients who presumably died from CO poisoning due to a heating system malfunction. All subjects tested positive for COVID-19 both ante- and post-mortem and were examined using post-mortem computed tomography prior to autopsy. COVID-19 was determined to be a contributing cause in the deaths of four out of nine subjects (death due to COVID-19; i.e., pneumonia and sudden cardiac death). In the other five cases, for which CO poisoning was identified as the cause of death, the infection presumably had no role in exitus (death with COVID-19). In our attempt to classify our patients as dying with or due to COVID-19, we found the use of complete assessments (both histological analyses and computed tomography examination) fundamental. Full article

(This article belongs to the Special Issue Forensic Epidemiology)

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9 pages, 550 KiB

Open AccessArticle

Medicolegal Causation Investigation of Bacterial Endocarditis Associated with an Oral Surgery Practice Using the INFERENCE Approach

by Putri Dianita Ika Meilia, Maurice P. Zeegers, Herkutanto and Michael D. Freeman

Int. J. Environ. Res. Public Health 2021, 18(14), 7530; https://doi.org/10.3390/ijerph18147530 - 15 Jul 2021

Cited by 1 | Viewed by 2697

Abstract

Investigating causation is a primary goal in forensic/legal medicine, aiming to establish the connection between an unlawful/negligent act and an adverse outcome. In malpractice litigation involving a healthcare-associated infection due to a failure of infection prevention and control practices, the medicolegal causal analysis needs to quantify the individual causal probabilities to meet the evidentiary requirements of the court. In this paper, we present the investigation of the most probable cause of bacterial endocarditis in a patient who underwent an invasive procedure at a dental/oral surgical practice where an outbreak of bacterial endocarditis had already been identified by the state Department of Health. We assessed the probability that the patient’s endocarditis was part of the outbreak versus that it was an unrelated sporadic infection using the INFERENCE (Integration of Forensic Epidemiology and the Rigorous Evaluation of Causation Elements) approach to medicolegal causation analysis. This paper describes the step-by-step application of the INFERENCE approach to demonstrate its utility in quantifying the probability of causation. The use of INFERENCE provides the court with an evidence-based, transparent, and reliable guide to determine liability, causation, and damages. Full article

(This article belongs to the Special Issue Forensic Epidemiology)

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18 pages, 2590 KiB

Open AccessArticle

Is Acceleration a Valid Proxy for Injury Risk in Minimal Damage Traffic Crashes? A Comparative Review of Volunteer, ADL and Real-World Studies

by Paul S. Nolet, Larry Nordhoff, Vicki L. Kristman, Arthur C. Croft, Maurice P. Zeegers and Michael D. Freeman

Int. J. Environ. Res. Public Health 2021, 18(6), 2901; https://doi.org/10.3390/ijerph18062901 - 12 Mar 2021

Cited by 4 | Viewed by 13375

Abstract

Injury claims associated with minimal damage rear impact traffic crashes are often defended using a “biomechanical approach,” in which the occupant forces of the crash are compared to the forces of activities of daily living (ADLs), resulting in the conclusion that the risk of injury from the crash is the same as for ADLs. The purpose of the present investigation is to evaluate the scientific validity of the central operating premise of the biomechanical approach to injury causation; that occupant acceleration is a scientifically valid proxy for injury risk. Data were abstracted, pooled, and compared from three categories of published literature: (1) volunteer rear impact crash testing studies, (2) ADL studies, and (3) observational studies of real-world rear impacts. We compared the occupant accelerations of minimal or no damage (i.e., 3 to 11 kph speed change or “delta V”) rear impact crash tests to the accelerations described in 6 of the most commonly reported ADLs in the reviewed studies. As a final step, the injury risk observed in real world crashes was compared to the results of the pooled crash test and ADL analyses, controlling for delta V. The results of the analyses indicated that average peak linear and angular acceleration forces observed at the head during rear impact crash tests were typically at least several times greater than average forces observed during ADLs. In contrast, the injury risk of real-world minimal damage rear impact crashes was estimated to be at least 2000 times greater than for any ADL. The results of our analysis indicate that the principle underlying the biomechanical injury causation approach, that occupant acceleration is a proxy for injury risk, is scientifically invalid. The biomechanical approach to injury causation in minimal damage crashes invariably results in the vast underestimation of the actual risk of such crashes, and should be discontinued as it is a scientifically invalid practice. Full article

(This article belongs to the Special Issue Forensic Epidemiology)

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16 pages, 10244 KiB

Open AccessArticle

INFERENCE: An Evidence-Based Approach for Medicolegal Causal Analyses

by Putri Dianita Ika Meilia, Maurice P. Zeegers, Herkutanto and Michael Freeman

Int. J. Environ. Res. Public Health 2020, 17(22), 8353; https://doi.org/10.3390/ijerph17228353 - 11 Nov 2020

Cited by 7 | Viewed by 3466

Abstract

A fundamental purpose of forensic medical, or medicolegal, analysis is to provide legal factfinders with an opinion regarding the causal relationship between an alleged unlawful or negligent action and a medically observed adverse outcome, which is needed to establish legal liability. At present, there are no universally established standards for medicolegal causal analysis, although several different approaches to causation exist, with varying strengths and weaknesses and degrees of practical utility. These approaches can be categorized as intuitive or probabilistic, which are distributed along a spectrum of increasing case complexity. This paper proposes a systematic approach to evidence-based assessment of causation in forensic medicine, called the INtegration of Forensic Epidemiology and the Rigorous EvaluatioN of Causation Elements (INFERENCE) approach. The INFERENCE approach is an evolution of existing causal analysis methods and consists of a stepwise method of increasing complexity. We aimed to develop a probabilistic causal analysis approach that (1) fits the needs of legal factfinders who require an estimate of the probability of causation, and (2) is still sufficiently straightforward to be applied in real-world forensic medical practice. As the INFERENCE approach is most relevant in complex cases, we also propose a process for selecting the most appropriate causal analysis method for any given case. The goal of this approach is to improve the reproducibility and transparency of causal analyses, which will promote evidence-based practice and quality assurance in forensic medicine, resulting in expert opinions that are reliable and objective in legal proceedings. Full article

(This article belongs to the Special Issue Forensic Epidemiology)

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16 pages, 459 KiB

Open AccessArticle

The Effects of Increasing Penalties in Drunk Driving Laws—Evidence from Chile

by Andrés García-Echalar and Tomás Rau

Int. J. Environ. Res. Public Health 2020, 17(21), 8103; https://doi.org/10.3390/ijerph17218103 - 3 Nov 2020

Cited by 7 | Viewed by 5511

Abstract

This paper analyzes Chile’s drunk driving laws and their effects on car crashes, injuries, and deaths. There were two policy changes. While the 2012 law increased license suspension penalties and decreased the legal blood alcohol limits for drivers, the 2014 law only increased sanctions, including at least one year of actual imprisonment for drunk driving implicated in car crashes with severe injury or death. We use a rich data set of countrywide administrative records that permit us to identify direct measures of alcohol-related accidents, including fatalities and injuries. We also have access to blood alcohol tests to assess whether the laws affected drivers’ alcohol consumption. Using count data models and a rich set of covariates, including police stops and gasoline sales, we find a short-run decrease in accidents and injuries for the 2012 law and a sustained decline in these outcomes for the 2014 law. Neither intervention has an effect on deaths. There is a marginal decline in alcohol consumption after the enactment of both legal changes. However, while the 2012 law only affects male drivers, the 2014 law affects both males and females. No reductions in alcohol intake are found for heavy drinkers. Full article

(This article belongs to the Special Issue Forensic Epidemiology)

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11 pages, 3341 KiB

Open AccessArticle

Clinical Relevance of Unexpected Findings of Post-Mortem Computed Tomography in Hospitalized Patients: An Observational Study

by Max G. Mentink, Bartholomeus G. H. Latten, Frans C. H. Bakers, Casper Mihl, Roger J. M. W. Rennenberg, Bela Kubat and Paul A. M. Hofman

Int. J. Environ. Res. Public Health 2020, 17(20), 7572; https://doi.org/10.3390/ijerph17207572 - 18 Oct 2020

Cited by 4 | Viewed by 2677

Abstract

Background and objective: The current literature describing the use of minimally invasive autopsy in clinical care is mainly focused on the cause of death. However, the identification of unexpected findings is equally important for the evaluation and improvement of daily clinical care. The purpose of this study was to analyze unexpected post-mortem computed tomography (PMCT) findings of hospitalized patients and assess their clinical relevance. Materials and methods: This observational study included patients admitted to the internal medicine ward. Consent for PMCT and autopsy was requested from the next of kin. Decedents were included when consent for at least PMCT was obtained. Consent for autopsy was not obtained for all decedents. All findings reported by PMCT were coded with an International Classification of Diseases (ICD) code. Unexpected findings were identified and subsequently categorized for their clinical relevance by the Goldman classification. Goldman class I and III were considered clinically relevant. Additionally, correlation with autopsy results and ante-mortem imaging was performed. Results: In total, 120 decedents were included and evaluated for unexpected findings on PMCT. Of them, 57 decedents also underwent an autopsy. A total of 1020 findings were identified; 111 correlated with the cause of death (10.9%), 508 were previously reported (49.8%), 99 were interpreted as post-mortem changes (9.7%), and 302 were classified as unexpected findings (29.6%). After correlation with autopsy (in 57 decedents), 24 clinically relevant unexpected findings remained. These findings were reported in 18 of 57 decedents (32%). Interestingly, 25% of all unexpected findings were not reported by autopsy. Conclusion: Many unexpected findings are reported by PMCT in hospitalized patients, a substantial portion of which is clinically relevant. Additionally, PMCT is able to identify pathology and injuries not reported by conventional autopsy. A combination of PMCT and autopsy can thus be considered a more comprehensive and complete post-mortem examination. Full article

(This article belongs to the Special Issue Forensic Epidemiology)

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Review

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13 pages, 780 KiB

Open AccessReview

Medial Branch Blocks for Diagnosis of Facet Joint Pain Etiology and Use in Chronic Pain Litigation

by Gordon E. Lawson, Paul S. Nolet, Adam R. Little, Anit Bhattacharyya, Vivian Wang, C. Adam Lawson and Gordon D. Ko

Int. J. Environ. Res. Public Health 2020, 17(21), 7932; https://doi.org/10.3390/ijerph17217932 - 29 Oct 2020

Cited by 3 | Viewed by 8718

Abstract

A commonly disputed medicolegal issue is the documentation of the location, degree, and anatomical source of an injured plaintiff’s ongoing pain, particularly when the painful region is in or near the spine, and when the symptoms have arisen as result of a relatively low speed traffic crash. The purpose of our paper is to provide health and legal practitioners with strategies to identify the source of cervical pain and to aid triers of fact (decision makers) in reaching better informed conclusions. We review the medical evidence for the applications and reliability of cervical medial branch nerve blocks as an indication of painful spinal facets. We also present legal precedents for the legal admissibility of the results of such diagnostic testing as evidence of chronic spine pain after a traffic crash. Part of the reason for the dispute is the subjective nature of pain, and the fact that medical documentation of pain complaints relies primarily on the history given by the patient. A condition that can be documented objectively is chronic cervical spine facet joint pain, as demonstrated by medial branch block (injection). The diagnostic accuracy of medial branch blocks has been extensively described in the scientific medical literature, and evidence of facet blocks to objectively document chronic post-traumatic neck pain has been accepted as scientifically reliable in courts and tribunals in the USA, Canada and the United Kingdom. We conclude that there is convincing scientific medical evidence that the results of cervical facet blocks provide reliable objective evidence of chronic post-traumatic spine pain, suitable for presentation to an adjudicative decision maker. Full article

(This article belongs to the Special Issue Forensic Epidemiology)

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