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Forensic Epidemiology Jan2020

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Forensic Epidemiology Jan2020 Meilia P, Herkutanto H, Freeman M, Zeegers M A Review of Causal Inference in Forensic Medicine Forensic Science, Medicine and Pathology 2020, in press Scienfitic concepts of causal analyses in disease and injury Prof. dr. Maurice Zeegers [email protected] LAW AND EPIDEMIOLOGY Opiate Allergy Case 49 year old man with a prior history of Coronary Artery Disease and 9 stents undergoes knee replacement surgery Hx states “codeine allergy In recovery complains of severe pain, and surgeon rx morphine Nurse reminds doc of allergy Patient dies within 20 minutes of injection Defense – he died due to bad heart 1 20 1 [email protected] Query US National Inpatient Sample (NIS) Pull all cases 2000-2009 coded for prior opiate allergy in which there was an allergic reaction to an opiate Look for death rate Pull all cases 2000-2009 of knee replacement surgery with a history of CAD and stent placement Look for cardiac-associated death rate 1 20 2 [email protected] Results Opiate – 43/10,000 exposures (1 in 233) Cardiac – 4/10,000 surgeries (1 in 2500) This yields an Comparative Risk of 10.8 or Probability of Causation of 91% Hazard period The time the two competing causes overlap There was 20 minutes between injection and death The cardiac deaths took place over a week There are 504 20 minute periods in a week 1 20 3 [email protected] Results Thus, the competing base rate of death secondary to the heart problems during the 20 minute hazard period was (504 X 2500) = 1,260,000 The CRR of causation attributable to the morphine = 1 in 233/ 1 in 1,260,000 5,408 to 1 (>99.9% Probability of Causation) 1 20 4 [email protected] The Epidemiological Probability Number of people (cases) with the injury of interest Total number of the people in the population from which these cases arise 1 20 6 [email protected] Forensic Epidemiology Epidemiology is a Forensic Epidemiology provide legal Medical Science that Fact-finders with evidence regarding investigates Probabilities a causal relation between an action and Determinants of and a medically observed harmful health outcomes in outcome human populations 1 20 5 [email protected] Probabilistic Causation Attribution (probability that the outcome would not have occurred if it were not for a particular exposure) How likely it is that a plaintiff’s whiplash is caused by the accident, taking into account her disease history, age and sex, and the specific circumstances of the accident? Forecasting (probability of an outcome given a particular exposure) Although X-ray use predicts broken bones very well, there is no causal relationship between the two Given the car crash circumstances what is the probability that the defendant was wearing a seatbelt. 1 20 7 [email protected] Examples of Investigative Questions Addressed by Forensic Epidemiologic Methods What is likelihood that the asbestos exposure that Mr X experienced during his employment at company Z caused his lung cancer? [email protected] 1 20 8 Examples of Investigative Questions Addressed by Forensic Epidemiologic Methods Could you estimate the probability that the leg amputation of Mrs Y could have been prevented if the delay in diagnosis would not have occurred? [email protected] 1 20 10 Examples of Investigative Questions Addressed by Forensic Epidemiologic Methods How likely is it that the heart failure of Mrs Y was indeed caused by the side effect of this drug? [email protected] 1 20 11 Examples of Investigative Questions Addressed by Forensic Epidemiologic Methods How likely is it that the bladder cancer of Mrs Y was caused by passive smoking during her imprisonment given the fact that she was an ex-smoker herself? [email protected] 1 20 15 Examples of Investigative Questions Addressed by Forensic Epidemiologic Methods What is the chance that the death that followed the administration of the opiate by 20 minutes was due to the drug and not to other (unknown) factors? [email protected] 1 20 14 2 Theory Health Risk Estimation Overview: Research Methods for Health Risk Estimation The Language of Epidemiologic Study Designs Randomized Clinical Trial Cohort Study Case control Study Factual Probabilities Probability of Disease and Injury Probability of Death Case Fatality Rate and Survival Rate Linking a Potential Causal Factor to Injury Risk Difference (RD) Relative Risk (RR) Comparative risk (CRR) Probability of Causation (PC) Attributable Proportion (AP) Sampling Error Probability Belief Probability 2 24 1 [email protected] Study designs 2 24 2 The cohort study 2 24 4 Hierarchy of study designs 2 24 6 Probability of disease and injury Number of people (cases) with the injury of interest Total number of the people in the population from which these cases arise 2 24 7 [email protected] Prevalence Total number of existing cases in a defined time period Total number of persons in the population to which these cases belong 2 24 8 [email protected] Incidence Total number of new cases in a defined time period Total number of persons in the population at the beginning of this period 2 24 9 [email protected] Relationship between incidence and prevalence incidence prevalence healing/mortality coffee 2 24 10 Probability of Death Total number of new deaths in a defined time period Total number of persons in the population at the beginning of this period 2 24 11 [email protected] 2009 Dutch medical negligence court case (NL 105.001.264) Pregnant plaintiff lacked to receive antihypertensive drugs which may have led to her subsequent stroke Probability of Causation: 75% The absolute risk of obtaining the stroke increased from 1 in 13,937 to 1 in 11,315 Court concluded that on the basis of such a low probability no liability could be inferred 2 24 13 [email protected] Linking a Potential Causal Factor to Injury Negative Positive Health Outcome Health Outcome Potential cause 10 (a) 20 (b) present (exposed) Potential cause 7 (c) 34 (d) absent (not exposed) [email protected] 2 24 14 The 2x2 contingency table The incidence of the negative health outcome when the potential cause is present (I1) equals a/(a+b) 10/30=0.30 The incidence of the negative outcome when the potential cause is absent (I0) equals c/(c+d) 7/41=0.17 Negative Positive Health Outcome Health Outcome Potential cause present (exposed) 10 (a) 20 (b) Potential cause absent (not exposed) 7 (c) 34 (d) [email protected] 2 24 15 The Risk Difference I1-I0=0.30-0.17=0.13 or 13% Negative Positive Health Outcome Health Outcome Potential cause present (exposed) 10 (a) 20 (b) Potential cause absent (not exposed) 7 (c) 34 (d) [email protected] 2 24 16 The Relative Risk I1/I0=0.30/0.17=1.76 Negative Positive Health Outcome Health Outcome Potential cause present (exposed) 10 (a) 20 (b) Potential cause absent (not exposed) 7 (c) 34 (d) [email protected] 2 24 17 The Comparative Risk a derivative of the RR aims to compare individual probabilities instead of group risks I1/I0 -> P1/P0 [email protected] 2 24 18 A Comparative Risk where RR equals the CRR frequency of serious injury in 100 randomly selected unrestrained drivers exposed to a 20 mph frontal collision, eg. 15% frequency of serious injury in 100 randomly selected restrained drivers exposed to the same collision severity and type, eg. 5% CRR is 0.15/0.05=3 [email protected] 2 24 19 A Comparative Risk where RR does not equal the CRR: Example when the numerator of the CRR is a per-event risk, and the denominator is a per-time risk Patient with a history of deep venous thrombosis (DVT) Pulmonary embolism (PE) occurs a week after a patient sustained a lower extremity fracture in a crash What caused the PE? Compare Probability of PE given a lower extremity fracture (a per event rate)] 1-week risk of PE in a patient of with DVT (a time dependent probability 2 24 20 [email protected] The Attributable Proportion under the Exposed (APe) or the Probability of Causation (PC) (I1/I0)/I1 = (RR-1)/RR = 0.43% Negative Positive Health Outcome Health Outcome Potential cause present (exposed) 10 (a) 20 (b) Potential cause absent (not exposed) 7 (c) 34 (d) [email protected] 2 24 22 Higher court toxic tort (CO4/303HR) Employer was held liable for the lung cancer of an employee Employee who was potentially exposed to asbestos but also a life-long smoker The APe for asbestos exposure was 55% The court therefore concluded that the employer was for 55% liable The court ignored that the APe for smoking is 80% 2 24 23 [email protected] 3 Examples Health Risk Estimation Health Risk Estimation Example: Car crash 35 The case facts An unrestrained 35 year-old man was traveling on a highway on a winter evening in a 2008 Nissan Altima sedan. His vehicle struck the rear of a slow moving large truck at highway speed in the right lane, causing the airbags in the vehicle to deploy and disabling the vehicle. Within approximately 30 seconds following the first collision the sedan was struck from behind by a semi- tractor trailer traveling at highway speed. The man was pronounced dead at the scene, and later examination revealed extensive skull fractures and brain and spinal cord disruptions, along with severe chest, abdomen, and spine injuries.
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