From posts to protection: Ethical considerations regarding forensic psychiatrists and a duty to warn based on social media.

Increasing use of social media in forensic mental health evaluations will lead to new challenges that must be resolved by forensic practitioners and the legal system. One such dilemma is the discovery of information that would typically trigger a legal duty and professional ethics obligation for mental health professionals to breach doctor-patient confidentiality to promote public safety and prevent harm to vulnerable third parties. Although the law and professional organizations offer clear guidance for practitioners in the treatment role, there is currently no clarity from the law or instruction from professional organizations on what mental health professionals should do if they discover such information during a confidential forensic evaluation. For example, a forensic evaluator may find evidence on social media of an evaluee's threats to seriously harm others, abuse of children and the elderly, or severely impaired driving. There are no clear guidelines for how a forensic psychiatrist should respond in these complicated situations. We review the legal concepts and historical evolution of confidentiality, privilege, and mandated reporter duties that forensic practitioners should consider in these legally ambiguous situations. Finally, we discuss ethics frameworks practitioners can implement to determine their most ethical course of action when faced with such dilemmas.

Voluntary intoxication, homicide, and mens rea: Past, present, and future.

Voluntary, or intentional, acute intoxication does not qualify for an insanity defense. However, in many jurisdictions, voluntary intoxication can create a diminished capacity to form a specific intent necessary for a criminal offense. This is a type of mens rea defense. Homicide provides a clear example where the absence of a required specific intent can lead to a lesser included crime that does not require that specific intent. Thereby, a mens rea defense may lessen a first-degree murder charge to a lesser degree or even manslaughter, depending on the jurisdiction. After reviewing the history of mens rea defenses and voluntary intoxication, we performed a search of LexisNexis for state statutes and case law regulating the use of voluntary intoxication in mens rea defenses, focusing on homicide-related offenses. In this article, we compare the different approaches that have developed to address this complex issue. We discuss why knowledge of these different approaches is essential to the practicing forensic examiner in relevant jurisdictions and explore developing issues in the area.

Outcomes of toric IOL implantation guided by iris-registered femtosecond laser capsulotomy markings.

PURPOSE: To assess the accuracy and stability of iris-registered femtosecond laser-assisted anterior capsule axis markings (compensating cyclotorsion) along with refractive and visual outcomes after toric IOL implantation. METHODS: This prospective case series included eyes with visually significant cataracts and regular corneal astigmatism ranging from 1.25D to 4.0D, which received FLACS and toric IOL implantation, at The Eye Institute of West Florida, Largo, Florida, USA. Preoperative iris registration was used in conjunction with a femtosecond laser platform to create cyclotorsion corrected axis marks at the capsulotomy edge to facilitate toric IOL axial alignment. Patients were examined one, seven and thirty days after surgery to assess capsulotomy marks axis, toric IOL axis along with visual and refractive outcomes. RESULTS: Eighteen eyes of 13 patients aged 74.35 ± 8.65 years were included. Mean pre-op CDVA was 0.24 ± 0.16 LogMAR, while mean post-op UDVA was 0.09 ± 0.09 LogMAR. Mean pre-op corneal astigmatism was 1.85 ± 0.41 D, decreasing to 0.24 ± 0.41 D of refractive astigmatism postoperatively (p < 0.001). The capsular toric axis markings were visible in 100% of eyes throughout the follow-up; the mean difference between intended capsulotomy mark axis and measured capsulotomy mark axis was 1.6°, 1.7° and 1.3 o at the 1, 7 and 30 day intervals (p > 0.05), respectively. No capsule-related or any other type of complications was noted. CONCLUSIONS: Iris-registered femtosecond laser-assisted anterior capsule axis markings are safe and may be considered as an alternative option to the known axis marking techniques for toric IOL axial alignment at the time of cataract surgery.

Dysfunctional tear syndrome: dry eye disease and associated tear film disorders - new strategies for diagnosis and treatment.

Dysfunctional tear syndrome (DTS) is a common and complex condition affecting the ocular surface. The health and normal functioning of the ocular surface is dependent on a stable and sufficient tear film. Clinician awareness of conditions affecting the ocular surface has increased in recent years because of expanded research and the publication of diagnosis and treatment guidelines pertaining to disorders resulting in DTS, including the Delphi panel treatment recommendations for DTS (2006), the International Dry Eye Workshop (DEWS) (2007), the Meibomian Gland Dysfunction (MGD) Workshop (2011), and the updated Preferred Practice Pattern guidelines from the American Academy of Ophthalmology pertaining to dry eye and blepharitis (2013). Since the publication of the existing guidelines, new diagnostic techniques and treatment options that provide an opportunity for better management of patients have become available. Clinicians are now able to access a wealth of information that can help them obtain a differential diagnosis and treatment approach for patients presenting with DTS. This review provides a practical and directed approach to the diagnosis and treatment of patients with DTS, emphasizing treatment that is tailored to the specific disease subtype as well as the severity of the condition.

Informed Consent at Gunpoint: When Psychiatry Affects Gun Ownership.

As states take more steps to connect patients' gun ownership to their mental health, psychiatrists are being asked to provide mental health information after clinical interviews as well as after confiscation. This move into the patient-physician relationship raises new questions about how psychiatrists should obtain informed consent when interviews may result in reports to legal authorities. Consent warnings are already practiced more in the breach than in the observance and informed consent is imperfect at its best. In communities torn by controversies surrounding gun control, vehement political views will further influence these established themes to result in unprecedented pressures on patient confidentiality. This analysis draws on new movements in ethical theory and behavioral medicine that go beyond balancing principles to question the use of psychiatry in firearm reporting, and support a vigorous practice of informed consent to protect both individuals and the communities they live in.

Incidental treatment of maxillary dysesthesia with maxillary sinus lift procedure--a case report.

A 54-year-old woman presented with an 8-month history of dysesthesia to the left palate with referred pain to the left infraorbital distribution after extraction of the left maxillary first and second premolars. The clinical and radiologic examination revealed an alveolar crestal bone dehiscence suggestive of an occult oral antral communication (OAC) that had spontaneously healed. Stimulation of the mucosa at this bony dehiscence consistently reproduced the dysesthesia. A sinus lift procedure was performed in this region for implant site development and also resulted in resolution of the dysesthesia. This case represents an instance in which surgical alteration of a trigger zone of neuropathic pain can result in its resolution.

Composite three-layer closure of oral antral communication with 10 months follow-up-a case study.

PURPOSE: We propose a 3-layer composite closure technique for an oral antral communication (OAC) while avoiding secondary donor site morbidity. PATIENTS AND METHODS: A patient had developed a 1-cm OAC after extraction of right maxillary first molar. The patient subsequently developed acute maxillary sinusitis. The patient was taken to the operating room, and a Caldwell-Luc procedure was performed. The bony window from the Caldwell-Luc was "press fit" over the bony OAC defect. Soft tissue closure was then achieved with a buccal fat pad flap and a buccal mucosal advancement flap. The patient was examined on postoperative day 5 and 1, 2, 3, 6, and 10 months postoperatively. RESULTS: The acute sinusitis had resolved. The soft tissue closure was successful. The bone graft remained intact, prevented sinus pneumatization, and restored continuity to the floor of the maxillary sinus. CONCLUSIONS: The presented technique for 3-layer closure of OACs allows for the stability of a double-layer closure of OAC with the added benefit of bone grafting from single operative site, achieving stable oral antral closure, bone grafting, and the avoidance of secondary donor site morbidity.

Thyroid crisis in the maxillofacial trauma patient.

Thyroid crisis, also known as thyroid storm, is a rare complication of thyrotoxicosis that results in a hypermetabolic and hyperadrenergic state. This condition requires prompt recognition and treatment because the mortality from thyroid crisis approaches 30%. Thyrotoxicosis alone will usually not progress to thyroid crisis. Thyroid crisis will typically be precipitated by some concomitant event such as infection, iodine-containing contrast agents, medications such as amiodarone, pregnancy, or surgery. Trauma is a rare precipitator of thyroid crisis. Several published studies have reported thyroid crisis resulting from blunt or penetrating neck trauma. Significant systemic trauma, such as motor vehicle accidents, has also been reported to precipitate thyroid crisis. It is very unusual for minor trauma to precipitate thyroid crisis. In the present study, we report the case of a patient who had incurred relatively minor maxillofacial trauma and developed thyroid crisis 2 weeks after the initial trauma.

Forensic neurology: a distinct subspecialty at the intersection of neurology, neuroscience and law.

Neurological evidence is increasingly used in criminal cases to argue that a defendant is less responsible for their behaviour, is not competent to stand trial or should receive a reduced punishment for the crime. Unfortunately, neurologists are rarely involved in such cases despite having the expertise to help to inform these decisions in court. In this Perspective, we advocate for the development of 'forensic neurology', a subspecialty of neurology focused on using neurological clinical and scientific expertise to address legal questions for the criminal justice system. We review literature suggesting that the incidence of criminal behaviour is higher in people with certain neurological disorders than the general public and that undiagnosed neurological abnormalities are common in people who commit crimes. We discuss the need for forensic neurologists in criminal cases to provide an opinion on what neurological diagnoses are present, the resulting symptoms and ultimately whether the symptoms affect legal determinations such as criminal responsibility or competency.

Forensic Neurology: Practice Considerations and Training Opportunities.

Neurologic evidence, including MRI, PET, and EEG, has been introduced in more than 2,800 criminal cases in the past decade, including 12% of all murder trials and 25% of death penalty trials, to argue whether neurologic diseases are present, contribute to criminal behavior, and ultimately whether the defendant is less criminally responsible, competent to stand trial, or should receive a reduced punishment for his or her crime. Unfortunately, neurologists are often not involved in these criminal cases despite being the medical specialty with the most relevant training and expertise to address these issues for the court. Reasons for the absence of neurologists in criminal cases include a lack of awareness from lawyers, judges, and other expert witnesses on the value of including neurologists in forensic evaluations, and the lack of experience, training, and willingness of neurologists to work as expert witnesses in criminal cases. Here, we discuss forensic neurology, a field bridging the gap between neurology, neuroscience, and the law. We discuss the process of performing forensic evaluations, including answering 3 fundamental questions: the neurologic diagnostic question, the behavioral neurology/neuropsychiatry question, and the forensic neurology question. We discuss practical aspects of performing forensic expert witness work and important ethical differences between the neurologist's role in treatment vs forensic settings. Finally, we discuss the currently available pathways for interested neurologists to receive additional training in forensic assessments.

Cataract surgery using two 3D visualization systems: Complication rates, surgical duration & comparison with traditional microscopes.

PURPOSE: To compare the complication rates and surgical duration of cataract surgery using two 3D visualization systems and a traditional binocular microscope among experienced and inexperienced surgeons. METHODS: This retrospective case series included 571 eyes that received cataract surgery using either heads up cataract surgery, via a 3D head mounted system (N = 148-Group 1) or a 3D display screen (N = 338 eyes-Group 2), or traditional binocular microscope (N = 85 eyes-Group 3). The surgical records of consecutive patients who underwent cataract surgery by two groups of surgeons (experienced and inexperienced) were reviewed. Patients in all groups received either femtosecond laser assisted cataract surgery (FLACS) or traditional phacoemulsification. Complication rate, as well as duration of cataract surgery were evaluated between all three visualization approaches, between experienced and inexperienced surgeons. RESULTS: There was no statistically significant difference in duration of surgery between all 3 visualization approaches for both experienced and inexperienced surgeons (p < 0.05). Furthermore, the type of surgical technique (manual or FLACS) did not affect the surgical duration for both experienced and inexperienced surgeons (p < 0.05). No intraoperative complications were demonstrated in the current cohort. CONCLUSIONS: The implementation of heads up-3D visualization either through a screen or a head mounted platform for cataract surgery seems to offer similar safety and efficiency as the traditional binocular microscope, and both experienced and inexperienced surgeons demonstrate the same outcomes in terms of safety and efficiency.

Work Intensity of Postoperative Care Following Implantation of Presbyopia-Correcting versus Monofocal Intraocular Lenses.

Purpose: To compare the work intensity of postoperative care following implantation of presbyopia-correcting intraocular lenses (IOLs) to that of standard monofocal IOLs. Patients and Methods: This open-label, multicenter, comparative study retrospectively reviewed the case records of cataract surgery patients who underwent bilateral implantation of either presbyopia-correcting IOLs (presby-IOL group; N=177) or standard monofocal IOLs (monofocal group; N=177). Outcome measures included the total time the patient spent in the office, number of visits, mean duration of visits, and the number of procedures and diagnostic tests during the first postoperative year. Outcome measures were compared between the first 90 days and days 91-365 after surgery. Results: Mean (±SD) time spent in the office during the first postoperative year was 5:50 ± 3:35 hours (H:MM) over 6.6 ± 2.9 visits in the presby-IOL group, compared to 3:38 ± 1:36 hours over 4.9 ± 1.6 visits in the monofocal IOL group (p <0.001). During the first 90 days, a presby-IOL patient spent 40 minutes longer in the office than a monofocal IOL patient (3:39 ± 1:38 hours vs 2.59 ± 1:13 hours) (p <0.001). During days 91-365, time in the office was 1:32 hours longer (p <0.001), and the mean visit duration was 8 minutes longer for the presby-IOL patients (p=0.002) than those with monofocal IOL. In addition, the presby-IOL patients underwent more procedures and diagnostic tests (p ≤0.001) as compared with standard monofocal cataract surgery patients. Conclusion: Patients implanted with presbyopia-correcting IOLs require significantly more clinic time, diagnostic testing, and procedures postoperatively as compared with standard monofocal cataract surgery patients.

Pragmatic Approaches to COVID-19 Related Ethics Dilemmas for Psychiatrists.

Psychiatrists face complex ethics dilemmas in the COVID-19 pandemic era when assessing dangerousness in patients or forensic evaluees who threaten to purposely infect others or spread the virus. Understanding local public health and medical quarantine laws for their jurisdictions can help guide treating psychiatrists in how to handle some of these situations; however, challenges occur when what is ethically best conflicts with the action that will confer the greatest protection against legal liability. Additionally, the calculus of weighing competing ethics considerations changes based on how relevant it is to the duties of a particular role (e.g., treatment, forensic, research, managed care, etc.) as well as the contextual factors of the situation. We present dialectical principlism as a framework to help psychiatrists resolve such ethics dilemmas related to the COVID-19 and future pandemics, illustrating how it can be applied in different roles (i.e., treatment versus forensic) and situations (i.e., when it is clear the danger of viral transmission is secondary to a delusion versus a delusion-like belief) to come to the best outcome that balances patient welfare, legal considerations, and societal safety. Occasionally, the most ethical action may entail small liability risks.

Real-World Experience with Intracapsular Administration of Dexamethasone Intraocular Suspension 9% for Control of Postoperative Inflammation.

Corticosteroids and non-steroidal anti-inflammatory drugs are commonly used prophylactically to control inflammation after ocular surgery. When prescribed as eye drops, as has been longstanding tradition, anti-inflammatory success is out of surgeons' hands, dependent on patient compliance and proper instillation technique. Sustained-release, intraoperatively administered anti-inflammatory drugs are emerging as another option. DEXYCU (dexamethasone intraocular suspension) 9% is the first and only intraocular corticosteroid FDA-approved for postoperative inflammation, whose sustained-release formulation provides a high initial release of drug, followed by a gradual tapering. Administration of the drug directly into the capsular bag following cataract surgery enables reliable placement proximal to target tissues, ensuring surgeon control and visibility of delivery, safety, and efficiency. This technique also minimizes contact with metabolically active tissues such as the corneal endothelium, iris, and ciliary body. In this paper, we review the available literature on dexamethasone intraocular suspension and summarize surgeons' consensus on best practices for intracapsular administration.

First Real-World, Multicenter, Post-Marketing, Retrospective Study of Dexamethasone Intraocular Suspension for Inflammation After Cataract Surgery.

Purpose: To evaluate dexamethasone intraocular suspension 9% (intraocular DXM) in real-world clinical use to manage inflammation associated with cataract surgery. Setting: Patients who underwent cataract surgery and received intraocular DXM at 22 outpatient eye surgery centers in the US. Design: Retrospective, observational chart review. Methods: Records of all patients who received intraocular DXM from March to December 2019 at participating centers were reviewed. Main Outcome Measures: Outcomes included anterior chamber cell (ACC) grades, anterior chamber flare (ACF) grades, and visual acuity, as well as intraocular pressure (IOP) and adverse events (AEs) at postoperative days (PODs) 1, 8, 14, 30. Descriptive statistics were generated. Results: The study population included 527 patients (641 eyes), with glaucoma history in 66 patients (80 eyes). Among eyes with recorded ACC grades, the percentage with grade 0 increased from 40% at POD 1 to 89.7% at POD 30, with similar results in eyes with glaucoma history. Among eyes with recorded ACF grades, the percentage with grade 0 increased from 78.4% at POD 1 to 97.1% at POD 30. At POD 30, 96.6% eyes with recorded results achieved target acuity. Mean IOP was 18.6 mmHg at POD 1 but declined to ≤15.2 mmHg thereafter. Investigators reported 22 AEs in 20 patients, all reported mild or moderate, the most common: IOP increase (7 events). Conclusion: Patients undergoing cataract surgery and treated with intraocular DXM showed favorable inflammatory and visual outcomes, without unanticipated safety problems, consistent with results of previous controlled clinical trials.

Argentinian Flag Sign and Its Management during Femtosecond Laser-Assisted Cataract Surgery in a Case with Intumescent Cataracts.

We describe a case of radial extension and its management during femtosecond laser-assisted cataract surgery (FLACS) in a patient with intumescent cataracts. Radial extension was observed after injection of trypan blue into the anterior chamber. Management of the extension was achieved by separation of adhesions between the incomplete capsulotomy, along with manual completion at the areas of extensions. Careful observation during FLACS capsulotomy is advised in cases of intumescent cataracts due to the release of cortex into the anterior chamber which may interfere with the delivery of the laser treatment resulting in incomplete capsulotomy patterns. Furthermore, trypan blue staining is essential to identify possible incomplete capsulotomy patterns and extensions. The Argentinian flag sign may occur after femtosecond laser-assisted capsulotomy in cases of intumescent cataracts. Proper identification of incomplete capsulotomy patterns and radial extensions should be managed with careful manual completion of the capsulotomy.

Comparative Assessment of Ergonomic Experience with Heads-Up Display and Conventional Surgical Microscope in the Operating Room.

PURPOSE: Musculoskeletal pain issues are prevalent in ophthalmic surgeons and can impact surgeon well-being and productivity. Heads-up displays (HUD) can improve upon conventional microscopes by reducing ergonomic stress. This study compared ergonomic outcomes between HUD and a conventional optical microscope in the operating room, as reported by ophthalmic surgeons in the US. METHODS: An online questionnaire was distributed to a sample of surgeons who had experience operating with HUD. The questionnaire captured surgeon-specific variables, the validated Nordic Musculoskeletal Questionnaire, and custom questions to compare HUD and conventional microscope. A multivariable model was built to identify variables that were likely to predict improvement in pain-related issues. RESULTS: Analysis was conducted on 64 surgeons (37 posterior-segment, 25 anterior-segment, and two mixed) with a mean 14.9 years of practice and 2.3 years using HUD. Most surgeons agreed or strongly agreed that HUD reduced the severity (64%) and frequency (63%) of pain and discomfort, improved posture (73%), and improved overall comfort (77%). Of respondents who experienced headaches, or pain and discomfort during operation, 12 (44%) reported their headaches improved and 45 (82%) reported feeling less pain and discomfort since they started using HUD. The multivariable model indicated the odds of reporting an improvement in pain since introducing the HUD in the operating room were 5.12-times greater for those who used HUD in >50% of their cases (P=0.029). CONCLUSION: This study indicates that heads-up display may be an important tool for wellness in the operating room as it can benefit ophthalmic surgeons across several ergonomic measures.

Polymorphisms in oxidative stress and inflammation pathway genes, low-dose ionizing radiation, and the risk of breast cancer among US radiologic technologists.

OBJECTIVE: Ionizing radiation, an established breast cancer risk factor, has been shown to induce oxidative damage and chronic inflammation. Polymorphic variation in oxidative stress and inflammatory-mediated pathway genes may modify radiation-related breast cancer risk. METHODS: We estimated breast cancer risk for 28 common variants in 16 candidate genes involved in these pathways among 859 breast cancer cases and 1,083 controls nested within the US Radiologic Technologists cohort. We estimated associations between occupational and personal diagnostic radiation exposures with breast cancer by modeling the odds ratio (OR) as a linear function in logistic regression models and assessed heterogeneity of the dose-response across genotypes. RESULTS: There was suggestive evidence of an interaction between the rs5277 variant in PTGS2 and radiation-related breast cancer risk. The excess OR (EOR)/Gy from occupational radiation exposure = 5.5 (95%CI 1.2-12.5) for the GG genotype versus EOR/Gy < 0 (95%CI < 0-3.8) and EOR/Gy < 0 (95%CI < 0-14.8) for the GC and CC genotypes, respectively, (p (interaction) = 0.04). The association between radiation and breast cancer was not modified by other SNPs examined. CONCLUSIONS: This study suggests that variation in PTGS2 may modify the breast cancer risk from occupational radiation exposure, but replication in other populations is needed to confirm this result.

Competence to be executed: An ethical analysis post Panetti.

Competence to be executed evaluations in effect can prevent an execution or remove the last meaningful impediment to it. Forensic psychiatrists have primary duties to the legal system and truth and honesty, but like all other areas of medical consultation also should balance conflicting secondary traditional medical ethical duties. Participation in a legally authorized execution so violates medical roles, that it is ethically prohibited by the American Medical Association and American Psychiatric Association. This prohibition includes treatment intended to restore competence to be executed. However, despite the primary treatment intent otherwise being appropriate ethically, like relieving suffering or fostering prison safety, if competence to be executed almost predictably would be a treatment result, at least the risk of this result should be considered ethically as if it were intended. In contrast, competence to be executed assessments can be ethical. Diamond's approach of performing honest evaluations only for the defense is an ethical option for such assessments. However, it is challenging to persuade judges and juries of the objectivity of such honest legitimate assessments. Most practitioners therefore likely would consider assessing competence to be executed for either side. This ethically hazardous position necessitates sensitivity to potentially seriously conflicting duties and roles.

Polymorphisms in estrogen biosynthesis and metabolism-related genes, ionizing radiation exposure, and risk of breast cancer among US radiologic technologists.

Ionizing radiation-associated breast cancer risk appears to be modified by timing of reproductive events such as age at radiation exposure, parity, age at first live birth, and age at menopause. However, potential breast cancer risk modification of low to moderate radiation dose by polymorphic estrogen metabolism-related gene variants has not been routinely investigated. We assessed breast cancer risk of 12 candidate variants in 12 genes involved in steroid metabolism, catabolism, binding, or receptor functions in a study of 859 cases and 1,083 controls within the US radiologic technologists (USRT) cohort. Using cumulative breast dose estimates from a detailed assessment of occupational and personal diagnostic ionizing radiation exposure, we investigated the joint effects of genotype on the risk of breast cancer. In multivariate analyses, we observed a significantly decreased risk of breast cancer associated with the CYP3A4 M445T minor allele (rs4986910, OR = 0.3; 95% CI 0.1-0.9). We found a borderline increased breast cancer risk with having both minor alleles of CYP1B1 V432L (rs1056836, CC vs. GG, OR = 1.2; 95% CI 0.9-1.6). Assuming a recessive model, the minor allele of CYP1B1 V432L significantly increased the dose-response relationship between personal diagnostic X-ray exposure and breast cancer risk, adjusted for cumulative occupational radiation dose (p (interaction) = 0.03) and had a similar joint effect for cumulative occupational radiation dose adjusted for personal diagnostic X-ray exposure (p (interaction) = 0.06). We found suggestive evidence that common variants in selected estrogen metabolizing genes may modify the association between ionizing radiation exposure and breast cancer risk.