Myxoid heart disease: a review with special emphasis on sudden cardiac death

Myxoid heart disease (MHD), more commonly known as mitral valve prolapse, is a very common cardiac abnormality affecting 5-10% of the general population. This article reviews the history, symptoms, physical findings, pathology, associated conditions and complications of this entity. Special emphasis is given to sudden cardiac death, which occurs as a result of acute heart failure or due to a fatal arrhythmia. Theories regarding the origin of the arrhythmias are discussed. Once the origin is known, those at risk for this devastating complication can be identified and perhaps a preventative therapeutic regimen developed.     

Post-mortem investigations of fatal cases of narcotic addiction

Organic lesions induced by narcotics are caused by the mode of application as well as directly or indirectly by the toxic effect of the substances.The cause of death is very often oedema of the lungs and brain, toxic circulatory failure or failure of certain vital organs, due to cellular degeneration.Narcotics abusers show mainly liver damage. Cell degeneration and infiltration of round cells have to be interpreted as drug hepatopathy and usually not as viral hepatitis.Histochemical tests show reduced enzyme levels in the impaired liver tissue. Toxic degeneration and inflammatory reactions are seen in the kidneys. Brain lesions are confined to cellular damage without necrotic degeneration of larger areas. Sporadically there are perivascular haemorrhages.The heart and the vascular system show mainly inflammatory reactions due to the application of the drug and rarely capillary embolism subsequent to the injection of dissolved tablets. Centrally stimulating substances cause hypertrophy of the tunica media in the pulmonary vessels combined with pulmonary hypertension.With progressive social collapse the drug addict suffers from dental caries, profound inflammatory periodontopathy as well as from fractures and fissures as a result of gnashing the teeth (bruxism).     

Myxoid heart disease: A review with special emphasis on sudden cardiac death

Myxoid heart disease (MHD), more commonly known as mitral valve prolapse, is a very common caridac abnormality affecting 5–10% of the general population. This article reviews the history, symptoms, physical findings, pathology, associated conditions and complications of this entity. Special emphasis is given to sudden cardiac death, which occurs as a result of acute heart failure or due to a fatal arrhythmia. Theories regarding the origin of the arrhythmias are discussed. Once the origin is known, those at risk for this devastating complication can be identified and perhaps a preventative therapeutic regimen developed.     

Risk, Need, And Responsivity (RNR): It All Depends

Target populations have always been a thorny issue for correctional programs, primarily in response to the question "what works for whom?" In this experiment of seamless treatment for probationers in two sites, offenders were randomly assigned to the seamless model (drug treatment incorporated into probation supervision) or traditional referral model to services in the community. The experiment blocked on risk level, using a version of the Wisconsin Risk Tool, to measure the differential effects on rearrest and substance abuse. The seamless system model improved treatment participation with greater gains for the high-risk offenders in both sites. Yet, no main effects were observed on drug use or rearrest, although effect sizes illustrate that small effects can be observed for the high-risk offenders and the direction of the effect size demonstrates negative effects for moderate-risk offenders in one of the sites. Part of the failure to observe main effects may be due to instrumentation and measurement problems, namely that many of the substance abusers in the experiment had low severity substance abuse problems and the majority of the offenders were marijuana users which has a weaker crime-drug linkage. Study findings illustrate the importance of theoretically driven and dynamic risk and need measures. The focus on sound dynamic factors may assist with identifying the appropriate target populations for correctional interventions.     

Fixed-dose isosorbide dinitrate-hydralazine: race-based cardiovascular medicine benefit or mirage?

Race is not a scientific category, but African Americans have increased prevalence and severity of heart failure. The African American Heart Failure trial showed the benefit of a combination of isosorbide dinitrate (a nitric oxide donor) and hydralazine (an antioxidant). Future research may unmask the reason for cardiovascular differences in therapy.     

Intellectual disability and mental illness in the NSW criminal justice system

There has been increasing international, national and local recognition of the need for more appropriate responses and services for individuals who come in contact with the criminal justice system and who have an intellectual disability and mental health issues. This article provides an overview of prevalence data that indicates a significant over representation of people with intellectual disabilities in correctional facilities and reviews the problems facing this population. Findings from two specific evaluation studies undertaken by the Centre for Developmental Disability Studies are presented, along with recommendations for future provision based on these results. One of these projects trialled a case management approach to supporting offenders with an intellectual disability upon their release from prison. The 20-month follow-up found that a number of serious barriers were encountered within the overall system of provision for this population; the most serious of which related to lack of adequate accommodation upon release. The second project involved a two-stage evaluation of one model of provision for individuals with intellectual disabilities who are sex offenders, only some of whom were on parole. This service provided both residential and therapy services in a small group home located in the community. Residents were found to have high levels of emotional and behavioural difficulties, in addition to offending behaviour, that continue to require support and supervision. Critical issues, including guardianship involvement, restrictive practices and retrieval, therapy provision, and risk management issues are discussed in relation to overall clinical and lifestyle outcomes.     

Restoring accountability in pretrial release: the Philadelphia pretrial release supervision experiments

As drug arrests and jail overcrowding added pressure to increase pretrial release in localities during the 1980s and 1990s, the need to manage a larger and higher-risk pretrial population of defendants awaiting adjudication in the community became a high priority for justice agencies. In the late 1990s Philadelphia officials sought to discover the ingredients of a successful supervision strategy through four interlinked field experiments to provide an empirical basis for a major reform of the pretrial release system. The results of the linked randomized experiments question common assumptions about “supervision,” its impact and effectiveness, about the underlying nature of the noncompliant defendant, and deterrence implications. The study emphasizes the importance of interpreting the findings in the context of implementation of the policy reform. Findings suggest that facilitative notification strategies wield little influence on defendant behavior and that deterrent aims are undermined by the system's failure to deliver consequences for defendant noncompliance during pretrial release. The most significant contribution of the article is its illustration of a major evidence-based policy reform undertaken by a major court system.     

Participation in drug treatment court and time to rearrest

This study uses an experimental design to assess the impact of a drug treatment court on nonviolent felony offenders. The drug court program combines intensive supervision, judicial monitoring, drug testing, and drug treatment to reduce recidivism and other problem behaviors. Survival analyses showed that the drug court sample had a significantly longer time to first rearrest than the control sample. Assignment to the drug court also significantly reduced the risk of drug crime failure during the follow-up period. The drug court and control samples had identical failure rates during the first 4 months of the follow-up, after which the drug court appeared to have its greatest impact on the risk of failure. Further analyses suggested that compliance with various drug court components, particularly early and continued drug treatment attendance, reduced the risk of failure among this sample.     

A systematic review of effective therapeutic interventions and management strategies for challenging behaviour in women in forensic mental health settings

Women in secure forensic mental health care require therapy and care that is responsive to their specific needs. Despite the policy recognition that women require a distinct service, evidence based practice is not available for this population. This review was undertaken in response to a clinical need within a medium secure unit in Glasgow that was experiencing high levels of challenging behaviour, in a female ward. The review aimed to identify effective strategies or interventions for the management of challenging behaviour in women in secure services and, therefore, improve practice and patient care. A synthesis of the findings from the 11 identified studies revealed variability in the approaches used to support women in forensic services, including: behavioural programmes; organisational change with a focus on staff training and support; medication; ECT and mechanical restraint. The challenging behaviours assessed included self-harm; physical and verbal aggression; suicide attempts and arson/fire setting. The majority of articles suggested some improvement in aspects of challenging behaviour, however this was limited by the lack of control groups and small sample sizes. Further investigation is required to find out whether interventions identified in this review can sustain a reduction in challenging behaviours in the long-term.     

Improving the quality of drug court clinical screening: a call for performance measurement policy reform

Despite the widespread use of the drug court model, standardized performance measures for drug courts are not uniformly utilized, and rarely include process measures. To ensure that drug courts are being implemented in the most effective manner, the use of performance measurement tools should be considered for wide scale adoption. Drug court effectiveness is moderated by participant characteristics, and is most effective for individuals with the highest substance use needs. Therefore, having quality clinical screening processes is crucial to ensuring that drug courts are serving the population for which they are effective. This paper examines clinical screening in drug courts, to answer the following 1) what is the current state of screening, 2) what works, and 3) why measurement matters. It also proposes a clinical screening performance measure to improve fidelity and ensure appropriate participant enrollment. The creation of a performance measure would create opportunities to improve drug court outcomes, and leverage pay-for-performance models.     

Homicidal behavior in schizophrenics

This paper emphasizes that homicidal behavior may be part of the clinical manifestation of schizophrenia. The failure to hospitalize potentially violent schizophrenics contributes to the incidence of psychotic homicide. The tendency to diagnose homicidal schizophrenics as personality disorders combined with legal changes brought about a shift of this population from the mental health system to the criminal justice system.     

Unexpected death as a result of infective endocarditis

Thirteen cases of infective endocarditis (IE) diagnosed for the first time at autopsy or, in those patients with a previous diagnosis of IE, not thought to be active at the time of death, are presented. Of the six patients who died within 24 h of the onset of symptoms, two died of obstruction of a valve orifice, two died of sepsis, one died of sepsis and alcoholic cardiomyopathy, and one died of a coronary artery embolus. Of the five patients with symptoms lasting more than 24 h, three died of sepsis and congestive heart failure. One died from sepsis alone and one died from congestive heart failure (CHF). In two patients whose duration of symptoms is unknown, one died of sepsis and CHF, and in the other the mechanism of death is unknown. Predisposing factors present in 11 of 13 patients included alcoholism (three), intravenous (IV) drug abuse (three), prosthetic valves (three), aortic stenosis (two), past rheumatic fever (one), and nonstenotic congenitally bicuspid valves (two). The reasons for no antemortem diagnosis were a missed or incorrect clinical diagnosis in three patients seen by a physician shortly before death, no signs or symptoms or found dead (four), non-specific signs and symptoms (three), refusal of medical treatment (one), and a solitary lifestyle (one); there was insufficient information about one patient. Individuals with needle tracks, generalized petechiae. Osler's nodes, splinter hemorrhages, intravenous catheters, pacemaker wires, and infected aortic-valve (A-V) shunts are at risk of IE. Blood and the vegetations should be cultured. The attending physician should be notified of the diagnosis in such cases.     

ADOLESCENT DRUG USERS: THE JUSTICE SYSTEM IS MISSING AN IMPORTANT OPPORTUNITY

A significant number of youth and young adults who use drugs have fallen through the cracks of our juvenile and adult justice systems in terms of receiving any meaningful services. The situation is due to a number of factors, including the reliance on adolescent self reporting utilized by most of the research, the failure of justice and other systems to routinely assess youth for either current drug use or indicia of drug use (e.g., "resiliency" or "protective" factors), and confidentiality and other restrictions pertaining to access to juvenile justice system information. Yet, retrospective reviews of drug use patterns for adults in the criminal justice system make it clear that drug use is beginning for most of these offenders during adolescence or before. This article urges (1) juvenile courts to develop mechanisms for systematically screening youth who come into the system for drug use and/or propensities for drug use and (2) adult courts to embark on similar strategies and to develop adolescent tracks that would be geared to providing the services these youth (despite their chronological age) need and would otherwise not receive in the adult system.     

Pulmonary thromboembolism after air travel: Two case reports, the review of literature and forensic implications

Anabolic androgenic steroids (AAS) are the main class of doping agents and their consumption produces adverse effects involving several organs and systems. Three cases of sudden cardiac death (SCD) and one of death due to congestive heart failure of previously healthy athletes who were AAS users are herein reported. Concentric cardiac hypertrophy with focal fibrosis (one case), dilated cardiomyopathy with patchy myocyte death (two cases) and eosinophilic myocarditis (one case) were observed and most probably relate to the final event. Molecular investigation for viral genomes was positive in one case (Ebstein virus). Our data confirm previous findings, showing that the most typical cardiac abnormality in AAS abusers is left ventricular hypertrophy, associated with fibrosis and myocytolysis. An exceptional cardiovascular substrate was represented by the case with drug induced eosinophilic myocarditis. These features are at risk of ventricular arrhythmias as well as congestive heart failure. The cause-effect relationship between AAS abuse and cardiac death can be established only by a rigorous methodology with the use of standardized protocols, including precise morphological studies of all target organs to search for chronic toxic effects. Laboratory investigations should focus on AAS searching on a wide range of biological matrices to demonstrate type, magnitude and time of exposure.     

Fatal poisoning by vanadium

We report here a fatal intoxication case involving ammonium vanadate. A 24-year-old woman was admitted to the Emergency Department for abdominal pain, nausea, vomiting, multiple daily diarrheas, hypoglycaemia (0.2g/L) and severe acute renal failure with glomerular filtration rate estimated at 21 ml/min. This patient had taken an undetermined amount of ammonium vanadate 12h after ingesting. She died next morning in the context of respiratory distress despite intensive care and oxygen therapy. The autopsy revealed widespread asphyxia syndrome and erosive gastritis. Determination of vanadium concentration in blood was carried out by means of mass spectrometer (ICP-MS) using rhodium ((103)Rh) as the internal standard. The vanadium concentration was 6.22 mg/L, corresponding to 6000 times higher than normal concentration in the general population. The latency and the brutality of clinical picture degradation seem to be in consideration of systemic poisoning by vanadium leading to inhibition of the cellular respiratory process.     

Sociological, social psychological, and psychopathological correlates of substance use disorders in the U.S. jail population

The objective of this study was to examine sociological, social psychological, and psychopathological correlates of substance abuse disorders in a nationally representative sample of jail inmates. Criminal history and clinical factors most strongly differentiated convicted inmates with and without substance use disorders regardless of current index offense. Policy implications are discussed in terms of targeting antisocial attitudes and peer associations and more effective clinical treatments for substance use disorders among the inmate population. High rates of co-occurring depression symptoms and anger dyscontrol found among inmates with substance use disorders in this study underscore the need for assessment and evaluation of specialized programs for co-occurring disorders and anger management programs among U.S. inmates.     

How voluntary must treatment of addicted patients be?

As for each medical treatment the principle of voluntariness also applies to the therapy of drug addicts. Indeed, under current drug influence or in an acute withdrawal situation a free will decision could not be possible. Also an excessive drug consumption over a longer period of time can lead to a severe personality disturbances. But from an--unreasonable--drug abuse one cannot conclude a general inability for making decisions of free will. For this reason the expressed will of the drug addict remains decisive. This applies also to juvenile addicts. Besides, one has to call in the parents as legal representatives. In case of consent to the therapy one should not be very exacting on the internal therapy readiness). It can also be awoken within the course of therapy (therapy to the therapy readiness). In case of a briefing in a withdrawal or penal institution a readiness to therapy is not required. But then there is only a state-obligation to offer therapies; for the single therapeutic measure the right of self-determination of the drug addict is further on valid.     

Life Stressors and Posttraumatic Stress Disorder in a Seriously Mentally Ill Jail Population,

Inmates represent a vulnerable population with increased rates of trauma and posttraumatic stress disorder (PTSD). However, little is known about the rates of trauma and PTSD among male inmates with acute psychiatric illness. This prospective, randomized study was conducted to assess the current rates of trauma and PTSD in this population. The sample consisted of 48 patients admitted to a hospital jail psychiatry service in New York City. Subjects were administered the Life Stressor Checklist‐Revised and the Structured Clinical Interview for DSM‐IV‐TR Disorders, PTSD Module (SCID‐I). The rate of PTSD diagnosis via SCID‐I was 46.2% as compared to 2.1% diagnosis via clinical interview. All participants reported a history of at least one stressful and/or traumatic event, and many of these events occurred during incarceration. These results demonstrate that a great deal of trauma and PTSD goes unrecognized and untreated in this population, indicating the need for more effective treatment interventions.