Extreme Risk Protection Orders: Legislative Intent and Clinician Guidance.

In this second column of a 2-part series exploring extreme risk protections orders, we utilize recent events in Colorado, including legislative efforts to expand the list of eligible petitioners to include clinicians, as an opportunity to explore questions and challenges faced by mental health and medical professionals serving in this capacity. Clinicians are in need of more clear guidance, given an emerging role that comes without clear evidence or practice standards to inform individualized clinical decision-making, and which potentially pits public safety interests against patient care needs, especially those pertaining to therapeutic relationships. In the interim, clinicians will best serve their patients by continuing to practice in a fashion that is analogous to decision-making around other interventions with serious implications for patient autonomy such as involuntary hospitalization.

When Restoration Fails: One State's Answer to the Dilemma of Permanent Incompetence.

The landmark 1972 U.S. Supreme Court decision in Jackson v.

Radiation Therapy for Residual or Recurrent Atypical Meningioma: The Effects of Modality, Timing, and Tumor Pathology on Long-Term Outcomes.

Background: Optimal use of stereotactic radiosurgery (SRS) vs external beam radiation therapy (EBRT) for treatment of residual/recurrent atypical meningioma is unclear.

Objective: To analyze features associated with progression after radiation therapy.

Methods: Fifty radiation-naive patients who received SRS or EBRT for residual and/or recurrent atypical meningioma were examined for predictors of progression using Cox regression and Kaplan-Meier analyses.

Clinical and Dosimetric Predictors of Acute Severe Lymphopenia During Radiation Therapy and Concurrent Temozolomide for High-Grade Glioma.

Purpose: Acute severe lymphopenia (ASL) frequently develops during radiation therapy (RT) and concurrent temozolomide (TMZ) for high-grade glioma (HGG) and is associated with decreased survival. The current study was designed to identify potential predictors of ASL, with a focus on actionable RT-specific dosimetric parameters.

Methods And Materials: From January 2007 to December 2012, 183 patients with HGG were treated with RT+TMZ and had available data including total lymphocyte count (TLC) and radiation dose-volume histogram parameters.

Impact of 1p/19q codeletion and histology on outcomes of anaplastic gliomas treated with radiation therapy and temozolomide.

Purpose: Anaplastic gliomas represent a heterogeneous group of primary high-grade brain tumors, and the optimal postoperative treatment remains controversial. In this report, we present our institutional data on the clinical outcomes of radiation therapy (RT) plus temozolomide (RT + TMZ) for anaplastic gliomas, stratified by histology and 1p/19q codeletion.

Methods And Materials: A single-institution retrospective review was conducted of patients with supratentorial anaplastic oligodendroglioma (AO), mixed anaplastic oligoastrocytoma (AOA), and anaplastic astrocytoma (AA).

Radiation therapy dose escalation for glioblastoma multiforme in the era of temozolomide.

Purpose: To review clinical outcomes of moderate dose escalation using high-dose radiation therapy (HDRT) in the setting of concurrent temozolomide (TMZ) in patients with newly diagnosed glioblastoma multiforme (GBM), compared with standard-dose radiation therapy (SDRT).

Methods And Materials: Adult patients aged <70 years with biopsy-proven GBM were treated with SDRT (60 Gy at 2 Gy per fraction) or with HDRT (>60 Gy) and TMZ from 2000 to 2012. Biological equivalent dose at 2-Gy fractions was calculated for the HDRT assuming an α/β ratio of 5.

Predictors of individual tumor local control after stereotactic radiosurgery for non-small cell lung cancer brain metastases.

Purpose: To evaluate local control rates and predictors of individual tumor local control for brain metastases from non-small cell lung cancer (NSCLC) treated with stereotactic radiosurgery (SRS).

Methods And Materials: Between June 1998 and May 2011, 401 brain metastases in 228 patients were treated with Gamma Knife single-fraction SRS. Local failure was defined as an increase in lesion size after SRS.

DSM-5 and neurocognitive disorders.

The newest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) introduces several changes in the diagnostic criteria for dementia and other cognitive disorders. Some of these changes may prove helpful for clinical and forensic practitioners, particularly when evaluating less severe cognitive impairments. The most substantial change is that the cognitive disorder-not otherwise specified category found in prior editions has been eliminated.

Management of atypical cranial meningiomas, part 2: predictors of progression and the role of adjuvant radiation after subtotal resection.

Background: The efficacies of adjuvant stereotactic radiosurgery (SRS) and external beam radiation therapy (EBRT) for atypical meningiomas (AMs) after subtotal resection (STR) remain unclear.

Objective: To analyze the clinical, histopathological, and radiographic features associated with progression in AM patients after STR.

Methods: Fifty-nine primary AMs after STR were examined for predictors of progression, including the impact of SRS and EBRT, in a retrospective cohort study.

Management of atypical cranial meningiomas, part 1: predictors of recurrence and the role of adjuvant radiation after gross total resection.

Background: Indications for external beam radiation therapy (EBRT) for atypical meningiomas (AMs) remain unclear.

Objective: To analyze features associated with recurrence in AM patients after gross total resection (GTR) and to assess the relative benefit of EBRT in a retrospective cohort study.

Methods: One hundred fifty-one primary AMs after GTR (88 female patients; median follow-up, 45.

A retrospective analysis of survival and prognostic factors after stereotactic radiosurgery for aggressive meningiomas.

Background: While most meningiomas are benign, aggressive meningiomas are associated with high levels of recurrence and mortality. A single institution's Gamma Knife radiosurgical experience with atypical and malignant meningiomas is presented, stratified by the most recent WHO classification.

Methods: Thirty-one patients with atypical and 4 patients with malignant meningiomas treated with Gamma Knife radiosurgery between July 2000 and July 2011 were retrospectively reviewed.

Codeletions at 1p and 19q predict a lower risk of pseudoprogression in oligodendrogliomas and mixed oligoastrocytomas.

Background: Pseudoprogression (PsP) occurs at a higher rate in glioblastoma multiforme with a methylated MGMT promoter-a subset with increased sensitivity to chemoradiotherapy and better overall prognosis. In oligodendroglioma (OG) and oligoastrocytoma (OA), presence of 1p/19q codeletions is highly predictive of response to treatment and is often associated with the methylated MGMT promoter; hence, this study queries whether the presence of 1p/19q codeletions in OG/OA correlates with a higher rate of PsP following therapy.

Methods: A retrospective analysis was performed on all OG/OA in a database of patients with brain tumors who underwent resection of their tumor since 1998.

Impact of time of day on outcomes after stereotactic radiosurgery for non-small cell lung cancer brain metastases.

Background: This study tested the hypothesis that time of day of treatment with stereotactic radiosurgery (SRS) has an effect on local control (LC) and overall survival (OS) in a large cohort of patients with non-small cell lung cancer (NSCLC) brain metastases.

Methods: At Washington University in St. Louis, 437 patients with NSCLC were treated with SRS for NSCLC brain metastases.

Survival following gamma knife radiosurgery for brain metastasis from breast cancer.

Background: Breast cancer is the second most common cause of brain metastases in the United States. Although breast cancer induced brain metastases represent an incurable condition, some patients experience prolonged survival. In this retrospective study, we examine a cohort of patients with brain metastases from breast cancer treated with Gamma Knife stereotactic radiosurgery to identify factors that predict better outcomes.

Acute Hemorrhage Following Gamma Knife Radiosurgery to a Clival Meningioma.

Background: Gamma Knife radiosurgery (GKS) is a primary treatment modality for small, surgically-challenging meningiomas of the skull base in carefully selected patients. Despite the overall low incidence of complications from this procedure, rare instances of hemorrhagic events following GKS have been reported. In fact, only a single, probable case of acute hemorrhage after GKS for a meningioma exists in the literature.

Recurrent adult-onset hypophyseal Langerhans cell histiocytosis after radiotherapy: a case report.

Introduction: Langerhans cell histiocytosis is a rare disease within the adult population, with very few cases reported as solitary hypophyseal lesions in adults. Of the reported cases, most have been treated successfully with surgery, radiotherapy, and/or chemotherapy. Radiotherapy has been thought to be curative at the relatively low dose of 20Gy.

Oligodendrogliomas in children.

Oligodendrogliomas are rare central nervous system (CNS) tumors in children. The purpose of this study was to identify prognostic factors for progression free survival (PFS) and overall survival (OS) in pediatric patients with oligodendrogliomas. We retrospectively analyzed clinical data on 37 pediatric patients with oligodendroglial tumors treated at Washington University.

Combined endovascular embolization and stereotactic radiosurgery in the treatment of large arteriovenous malformations.

Object: Large cerebral arteriovenous malformations (AVMs) are often not amenable to direct resection or stereotactic radiosurgery (SRS) treatment. An alternative treatment strategy is staged endovascular embolization followed by SRS (Embo/SRS). The object of this study was to examine the experience at Washington University in St.

Glioblastoma in children: a single-institution experience.

Purpose: Current treatment recommendations for pediatric glioblastoma include surgery, chemotherapy, and radiation therapy. However, even with this multispecialty approach, overall survival remains poor. To assess outcome and evaluate treatment-related prognostic factors, we retrospectively reviewed the experience at our institution.

Functional MRI lie detection: too good to be true?

Neuroscientists are now applying a 21st-century tool to an age-old question: how can you tell when someone is lying? Relying on recently published research, two start-up companies have proposed to use a sophisticated brain-imaging technique, functional magnetic resonance imaging (fMRI), to detect deception. The new approach promises significantly greater accuracy than the conventional polygraph--at least under carefully controlled laboratory conditions. But would it work in the real world? Despite some significant concerns about validity and reliability, fMRI lie detection may in fact be appropriate for certain applications.

Mental health weapons prohibition: demographic and psychiatric factors in petitions for relief.

Federal law and most states prohibit possession of firearms by individuals with a history of certain psychiatric diagnoses and/or treatment. In California, an involuntary 72-h hold can trigger a 5-year ban on firearm possession. Individuals so prohibited may petition for early termination of the ban.

Combined surgical resection and stereotactic radiosurgery for treatment of cerebral metastases.

Background: Patients with limited intracranial metastatic disease traditionally have been treated with surgery followed by WBRT. However, there is growing concern for the debilitating cognitive effects after WBRT in long-term survivors. We present a series of patients treated with surgery followed by SRS, while reserving WBRT as a salvage therapy for disease progression.