Left Ventricular Septal Avulsion in the Setting of Blunt Cardiac Injury.

A 23-year-old man sustained blunt cardiac injury after a motor vehicle collision resulting in left ventricular septal avulsion, ruptured chordae tendineae, and moderate to severe tricuspid regurgitation that necessitated operative intervention. The patient underwent successful resection of a prolapsed avulsed septal wall segment and concomitant tricuspid valve repair.

The imperfect fit: Fetal alcohol spectrum disorder as the basis to commit individuals involuntarily as sexually violent predators/persons.

Prenatal alcohol exposure produces a broad range of primary disabilities that lead to adverse life course outcomes in children raised in adverse environments. Inappropriate sexual behaviors are a commonly occurring secondary disability, with a large minority of individuals with fetal alcohol spectrum disorder (FASD) displaying sexual aggression. Adults with FASD who commit repeated criminal sexual acts may be subject to legal proceedings for indefinite involuntary civil confinement as sexually violent predators/persons (SVP) in certain jurisdictions in the United States. Studies about the diagnostic practices among psychologists and psychiatrists retained by states to evaluate individuals as SVP do not recognize FASD as a mental disorder, despite the likelihood that hundreds of individuals petitioned for involuntary commitment suffer from FASD. Establishing an FASD diagnosis may provide exculpatory evidence to refute a government petition that an individual suffers from a mental condition that affects emotional or volitional capacity by predisposing the person to committing criminal sexual behavior. This article provides a framework for identifying, assessing, and deciding whether individuals with the FASD diagnosis suffer from the legally defined mental disorder that is necessary to indefinitely confine individuals as SVP.

Reducing Time to Discharge after Chemotherapy by Standardizing Workflow and Providing Outpatient Intravenous Hydration.

INTRODUCTION: Patients receiving cyclophosphamide or ifosfamide chemotherapy require intravenous fluid hydration to prevent hemorrhagic cystitis. In selected patients without medical contraindications (ie, excess nausea/vomiting), this hydration may be completed after discharge. We aimed to reduce the time to discharge after completing mesna in patients receiving cyclophosphamide or ifosfamide therapy on an inpatient chemotherapy service. METHODS: The quality improvement team performed a medical record review to capture the time to discharge after mesna therapy and the readmission rate and used quality improvement methods to redesign discharge workflow and increase patient involvement with the discharge process. RESULTS: From August 2017 through July 2018, there were 160 admission encounters (73 patients) for cyclophosphamide or ifosfamide on a dedicated chemotherapy service. Of those encounters, 89 (55.6%) were appropriate for outpatient hydration; 48 (53.9%) of these encounters involved a patient who elected to receive outpatient hydration. Although the median time to discharge for the whole cohort did not change, in encounters where patients chose intravenous outpatient hydration, the median time to discharge was reduced from 2.82 to 0.66 hours (76.6% reduction) after implementing the new discharge workflow. No patients experienced readmission within 48 hours. CONCLUSIONS: Discharge workflow redesign and standardization reduced the time to discharge after chemotherapy in patients who chose outpatient hydration. Outpatient intravenous hydration after cyclophosphamide or ifosfamide appears safe and feasible in selected patient populations.

Illuminating the dark figure of sexual recidivism.

Detected or reported ("observed") rates of sexual reoffending have long been recognized as underestimating the occurrence of actual sexual recidivism. Past attempts to bridge the gap between the two rates have been unsuccessful. Scurich and John try to reverse this course by presenting a simulation model to estimate the predicted actual sexual recidivism rates among individuals convicted of sexual offenses based on three parameters; they also apply these data to calibrate the sexual recidivism rates from four sexual recidivism studies. The accuracy of the predicted actual sexual recidivism rates is wholly dependent upon the reliability of the inputs to the model. This analysis relies upon scientific studies and literature to delve into the precision of the parameters of Scurich and John in relation to the accuracy of their predicted actual sexual recidivism rates and the validity of the calibration process. The results reveal that some of the assumptions by Scurich and John about the parameters are supported empirically, while others are not. Overall, the simulation model parameters suffer from significant deficiencies that likely produce inaccurate predicted actual sexual recidivism rates. Moreover, the methodologies of the comparison studies used in the calibration process do not actually meet the requirements of the analytic strategy of Scurich and John, which effectively invalidates their findings. Until computational strategies are employed that account for linear and nonlinear effects of model parameters, closing the gap between observed and actual sexual recidivism rates will remain elusive.

Multimodal Imaging for the Diagnosis of Isolated Cardiac Sarcoidosis.

We report a case of isolated cardiac sarcoidosis (CS) diagnosed using a multimodality imaging approach. A patient presented after an out-of-hospital, ventricular fibrillation-mediated cardiac arrest. The use of echocardiography, cardiac magnetic resonance, and fluorodeoxyglucose-positron emission tomography enabled the diagnosis of isolated CS. (Level of Difficulty: Beginner.).

Contemporary Cardiac SPECT Imaging-Innovations and Best Practices: An Information Statement from the American Society of Nuclear Cardiology.

This information statement from the American Society of Nuclear Cardiology highlights advances in cardiac SPECT imaging and supports the incorporation of new technology and techniques in laboratories performing nuclear cardiology procedures. The document focuses on the application of the latest imaging protocols and the utilization of newer hardware and software options to perform high quality, state-of-the-art SPECT nuclear cardiology procedures. Recommendations for best practices of cardiac SPECT imaging are discussed, highlighting what imaging laboratories should be doing as the standard of care in 2018 to achieve optimal results (based on the ASNC 2018 SPECT guideline [Dorbala et al., J Nucl Cardiol. 2018. https://doi.org/10.1007/s12350-018-1283-y ]).

Myocardial perfusion imaging in women for the evaluation of stable ischemic heart disease-state-of-the-evidence and clinical recommendations.

This document from the American Society of Nuclear Cardiology represents an updated consensus statement on the evidence base of stress myocardial perfusion imaging (MPI), emphasizing new developments in single-photon emission tomography (SPECT) and positron emission tomography (PET) in the clinical evaluation of women presenting with symptoms of stable ischemic heart disease (SIHD). The clinical evaluation of symptomatic women is challenging due to their varying clinical presentation, clinical risk factor burden, high degree of comorbidity, and increased risk of major ischemic heart disease events. Evidence is substantial that both SPECT and PET MPI effectively risk stratify women with SIHD. The addition of coronary flow reserve (CFR) with PET improves risk detection, including for women with nonobstructive coronary artery disease and coronary microvascular dysfunction. With the advent of PET with computed tomography (CT), multiparametric imaging approaches may enable integration of MPI and CFR with CT visualization of anatomical atherosclerotic plaque to uniquely identify at-risk women. Radiation dose-reduction strategies, including the use of ultra-low-dose protocols involving stress-only imaging, solid-state detector SPECT, and PET, should be uniformly applied whenever possible to all women undergoing MPI. Appropriate candidate selection for stress MPI and for post-MPI indications for guideline-directed medical therapy and/or invasive coronary angiography are discussed in this statement. The critical need for randomized and comparative trial data in female patients is also emphasized.

Radiation Safety in Children With Congenital and Acquired Heart Disease: A Scientific Position Statement on Multimodality Dose Optimization From the Image Gently Alliance.

There is a need for consensus recommendations for ionizing radiation dose optimization during multimodality medical imaging in children with congenital and acquired heart disease (CAHD). These children often have complex diseases and may be exposed to a relatively high cumulative burden of ionizing radiation from medical imaging procedures, including cardiac computed tomography, nuclear cardiology studies, and fluoroscopically guided diagnostic and interventional catheterization and electrophysiology procedures. Although these imaging procedures are all essential to the care of children with CAHD and have contributed to meaningfully improved outcomes in these patients, exposure to ionizing radiation is associated with potential risks, including an increased lifetime attributable risk of cancer. The goal of these recommendations is to encourage informed imaging to achieve appropriate study quality at the lowest achievable dose. Other strategies to improve care include a patient-centered approach to imaging, emphasizing education and informed decision making and programmatic approaches to ensure appropriate dose monitoring. Looking ahead, there is a need for standardization of dose metrics across imaging modalities, so as to encourage comparative effectiveness studies across the spectrum of CAHD in children.

Sexually violent predator risk assessments with the violence risk appraisal guide-revised: A shaky practice.

Twenty-two jurisdictions in the United States permit the involuntary civil confinement of sexual offenders upon expiration of their criminal sentence and, if committed, these individuals face possible lifetime commitment. One of the legal requirements that psychologists must address in sexually violent predator evaluations is the likelihood that an individual will engage in dangerous sexual behavior and consideration of the probabilities for sexual recidivism contained in actuarial experience tables best address this inquiry. Clinicians find it increasingly difficult to affirm the likelihood threshold in the face of decreasing base rates and score-wise probability estimates for sexual recidivism reported in contemporary actuarial experience tables. The Violence Risk Appraisal Guide-Revised (VRAG-R) has been promoted to assess sexually violent predators because it has been presented as a more accurate predictor of sexual recidivism and the results more likely satisfy the legal standard of sexual dangerousness. This article conducts an in-depth analysis of the predictive and psychometric properties of the VRAG-R that are most relevant to the fit of the VRAG-R when addressing the sexual dangerousness standard proscribed by SVP laws. Recommendations for future research are offered to improve the fit of the VRAG-R to the legal inquiry of sexual dangerousness and implications for using the current iteration of the VRAG-R in forensic practice are discussed.

A 9,000-year-old caribou hunting structure beneath Lake Huron.

Some of the most pivotal questions in human history necessitate the investigation of archaeological sites that are now under water. Nine thousand years ago, the Alpena-Amberley Ridge (AAR) beneath modern Lake Huron was a dry land corridor that connected northeast Michigan to southern Ontario. The newly discovered Drop 45 Drive Lane is the most complex hunting structure found to date beneath the Great Lakes. The site and its associated artifacts provide unprecedented insight into the social and seasonal organization of prehistoric caribou hunting. When combined with environmental and simulation studies, it is suggested that distinctly different seasonal strategies were used by early hunters on the AAR, with autumn hunting being carried out by small groups, and spring hunts being conducted by larger groups of cooperating hunters.

Dasatinib: from treatment of imatinib-resistant or -intolerant patients with chronic myeloid leukemia to treatment of patients with newly diagnosed chronic phase chronic myeloid leukemia.

BACKGROUND: Imatinib is an effective treatment for patients with newly diagnosed chronic phase chronic myeloid leukemia (CML-CP), but resistance to imatinib can occur. Second-generation BCR-ABL inhibitors have shorter onset times and higher rates of complete cytogenetic response (CCyR) than imatinib. Dasatinib has a half-maximal inhibitory concentration 325 times lower than imatinib for BCR-ABL substrate phosphorylation in vitro and is less susceptible to most known molecular mechanisms of BCR-ABL imatinib resistance. OBJECTIVES: This study summarized published data on the use of dasatinib in CML-CP, reviewed the importance of early response to therapy, and discussed additional therapies for patients with newly diagnosed disease. METHODS: PubMed was searched through June 2011 for English-language publications with the following search terms: imatinib, dasatinib, nilotinib, chronic myeloid/myelogenous leukemia or CML, and clinical trial. To identify follow-up data from published trials and data on trials in progress and products in development, similar searches were conducted for abstract and clinical trial databases. Relevant articles and abstracts were identified as those reporting results of Phase II and III clinical trials, predictors of treatment response, and treatment guidelines. No prespecified inclusion or exclusion criteria were used. RESULTS: Dasatinib was effective in patients resistant to imatinib and more effective than high-dose imatinib in patients with newly diagnosed CML who were resistant to standard dose imatinib. Compared with imatinib, dasatinib induced superior response rates and patient outcomes earlier in the disease. In a Phase III trial in patients with newly diagnosed CML-CP, dasatinib 100 mg once daily induced significantly higher and faster rates of confirmed CCyR and major molecular response by 12 months versus imatinib and was generally well tolerated. Early achievement of CCyR was associated with better long-term progression-free survival. Dasatinib was approved by the U.S. Food and Drug Administration and the European Medicines Agency for initial treatment of CML-CP. CONCLUSIONS: Dasatinib was an effective treatment with the potential to improve long-term outcomes for patients with newly diagnosed CML-CP.

Stress-only or stress/rest myocardial perfusion imaging in patients undergoing evaluation for bariatric surgery.

BACKGROUND: Bariatric surgery for management of obesity is being used with increasing frequency. Stress testing with myocardial perfusion imaging is often employed as part of the workup prior to anticipated bariatric surgery. The incidence of clinically significant abnormalities on stress MPI performed for this indication, however, has not been established. METHODS AND RESULTS: We retrospectively reviewed a series of 383 consecutive stress MPI studies performed on patients undergoing workup prior to planned bariatric surgery. The study population had a mean age 42 ± 10 years, and was 83% female, with a body mass index of 49 ± 8. The majority of patients (81%) were able to exercise using either the Bruce or Modified Bruce protocol, and 67% underwent stress-only imaging. Overall SPECT MPI findings were normal in 89% and equivocal in 6% of patients. The incidence of abnormal findings on MPI was 5% (3% mild and 2% moderate-to-severe abnormalities). At 1 year, overall survival was 99.5%, with no difference between those with and without MPI abnormalities. Similarly, the incidence of post-operative cardiac events was very low (2%), and mostly due to atrial arrhythmias or borderline elevations of troponin. CONCLUSION: In a typical pre-bariatric surgery population, the incidence of abnormal stress MPI is low. The majority of patients were able to use a stress-only strategy for assessment of perfusion. At 1 year the incidence of adverse cardiovascular outcomes is very low. Additional studies should be focused on determining whether any subgroup of such patients may benefit more from pre-operative stress testing.

Throwing the baby out with the bath water: is it time for clinical judgment to supplement actuarial risk assessment?

The assessment of the potential for sexual violence is one of three prongs that must be met to satisfy the requirements for civil confinement of dangerous sex offenders in the 21 U.S. jurisdictions that have these laws. In a recent issue of The Journal, Sreenivasan et al. argued that, because of a host of methodological problems, actuarial risk assessment methods in general and the Static-99 and its progeny in particular are insufficient for accurate assessment of risk for dangerous sex offenders. They propose using a combination of clinical judgment with actuarial science as a solution. This analysis and review of Sreenivasan et al. reveals and corrects flaws in the arguments they employed to support their position and shows how the combination of actuarial science with clinical judgment is more error prone than the actuarial approach only, and cannot be forensically defended in court. Recommendations on reporting Static-99R data in expert testimony are provided, taking into account the limitations of the instrument.