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Abstract: The mental health laws of many jurisdictions provide an enabling framework for the use of community treatment orders (CTOs), or ‘outpatient commitment’ as it is called in the USA. But the legislation does not usually say when CTOs must be used: this remains a matter for the discretion of clinicians. So the argument is made here that the rate at which CTOs are used in practice depends on the manner in which clinicians exercise their discretion when implementing the CTO regime. Furthermore, it is suggested that clinicians will exercise that discretion, to place a person on a CTO, when they believe the overall balance of advantage favours that option. Several factors are then identified as relevant to that calculation: the powers provided to treat involuntary outpatients; the threat of liability being imposed on clinicians for the conduct of patients in the community; the structure and quality of the mental health services available; the perceived impact of coercion on therapeutic relationships; the expectations of third parties; and past patterns of involuntary outpatient care. These factors provide a complex network of influences on the exercise of clinical discretion in the use of CTOs. Interaction between these factors produces a dynamic and fluid situation. Widely varying rates of use of CTOs can therefore develop in different jurisdictions with otherwise similar legal traditions, and rapid changes can occur in the rate of use of CTOs, over time, even within a single jurisdiction, without any change occurring in the law. [Copyright &y& Elsevier]

Background: The impact of intravascular ultrasound (IVUS) utilization for stent optimization on the long-term outcomes in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study., Methods: We examined the outcomes of CTO-PCI with and without IVUS use for stent optimization in 922 CTO-PCIs performed between 2012 and 2019 at 12 United States centers. Major adverse cardiac event (MACE) was defined as the composite of cardiac death, acute coronary syndrome, and target-vessel revascularization., Results: IVUS was used in 344 procedures (37%) for stent optimization. Mean patient age was 65 ± 10 years and 83% were men. Patients in the IVUS group were less likely to have a prior myocardial infarction (39% vs 50%; P<.01), more likely to undergo right coronary artery CTO-PCI (49% vs 55%; P=.01), and had higher mean J-CTO score (2.6 ± 1.1 vs 2.4 ± 1.2; P=.04). The final crossing strategy in patients in the IVUS group was less likely to be antegrade wire escalation (54% vs 57%) and more likely to be retrograde (29% vs 21%; P<.01). Median follow-up was 141 days (interquartile range, 30-365 days). The incidence of 12-month MACE was similar in the IVUS and no-IVUS groups (20.3% vs 18.3%; log-rank P=.67)., Conclusion: IVUS was used for stent optimization in approximately one-third of CTO-PCIs. Despite higher lesion complexity in the IVUS group, the incidence of MACE was similar during follow-up.