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By: John Theodore Geneczko, MD

  • Assistant Professor of Medicine

https://medicine.duke.edu/faculty/john-theodore-geneczko-md

The focus will be on the use of slide templates gastritis chronic fatigue syndrome generic pariet 20 mg otc, color selection (font and background) gastritis y colitis generic 20 mg pariet visa, font and image size gastritis symptoms tiredness purchase pariet 20mg free shipping, and animations gastritis severa buy 20mg pariet otc. Demonstrations will include tips to decrease time creating and modifying presentations. A re-examination of when it is appropriate not to use positive oral contrast will be discussed, and include rapid patient triage in the emergency setting, certain subsets of abdominopelvic imaging, and patient tolerance. The economic and radiation dose cost of positive oral contrast use will also be explored. Successful radiology global health initiatives in resource limited environments require an objective analysis of site Radiology Readiness and open communication with partners bilaterally. The same proves true on the international level in regards to development and dissemination of guidelines impacting the practice of radiology within a global health perspective. A brief interactive review of common, but atypical presentations of both benign and malignant liver lesions will be presented. Malignant mimics of benign liver lesions will also be shown, with features that should be analyzed in order to better characterize the lesion, and appropriately raise concern (eg, for a metastasis or intrahepatic cholangiocarcinoma instead of a benign hemangioma). Participants will understand in which situations to use which radio tracers, what to consider when developing the imaging construct and what controls to obtain for nuclear imaging studies. Examples will contain imaging with small molecules, with antibodies and nanoparticles as well as with cells in order to provide the participants with examples how o correctly perform their imaging studies. Most of the examples will be from the oncology field but their underlying principles are universally applicable to other areas as well. Therefore, it is not surprising that it is also highly frequented in preclinical imaging applications since it is currently the only true quantitative imaging method. In this talk, we will discuss the application of radio tracers to molecular imaging and what to consider. Common pitfalls and mistakes as well as required measures to avoid these will be discussed. We will discuss various examples of imaging constructs, ranging from small molecules to antibodies, nanoparticles and even cells. The primary focus will be advances in novel theranostic approaches for precision medicine. Integrating nanomedicine with novel multi-modality imaging technologies spurs the development of new personalized diagnostic tests and theranostic (combined diagnostic and therapeutic) procedures. A slow phagocytosis by macrophages in inflammations and high grade tumors can be used to grade the severity of the disease process and monitor new immune-modulating therapies. Novel developments include synthesis of multi-functional nanoparticles, which can be detected with two or more imaging modalities, as well as clinically applicable approaches for in vivo tracking of stem cell therapies. Ongoing pre-clinical developments include the development of improved, targeted and activatable nanoparticle formulations, which can further improve sensitivity, specificity and theranostic imaging capabilities. This approach has worked well, but modern imaging also is digital, quantitative and has the opportunity for more quantitative and objective interpretations. This lecture will focus on a few areas in which quantitative imaging is augmenting qualitative image assessments to lead to more precise interpretation of images. However, the quality of quantitation may vary and close attention to technical methodologies and process are required to have reliable and accurate quantitation. Examples of the use of quantitative phenotyping to inform patient management will be discussed. The talk will also discuss the spread patterns of the different primary sites of the larynx and illustrate the information that imaging provides that directly affects staging and management of laryngeal cancer. The information provided on pre-treatment imaging directly affects the stage of the tumor and provides information regarding management and treatment that cannot be ascertained through physical exam or staging. This talk will review the normal anatomy and malignancies involving the oral cavity and oropharynx. This multisession course will review data from North American and European trials, with emphasis on mortality reduction, cost-effectiveness, and stage shift; classification of lung nodules by appearance and size, measurement of nodule growth, and management strategies; elements of an effective clinical screening program; and the evidence for limiting screening to patients who meet current eligibility criteria based on age and smoking history versus including patients on the basis of expanded criteria. For this study, participants were selected with solid non-calcified nodules, newly detected after baseline and also in retrospect not present on any previous screen. Nodule volume was generated semi-automatically by Lungcare software (Siemens, Erlangen, Germany). Lung cancer diagnosis was based on histology, and benignity was based on either histology or a stable volume for at least two years. However, radiologists consider additional morphological features when assigning a malignancy risk. Goal of the study was to determine the power of additional morphological features to differentiate between benign and malignant nodules. Seven radiologists were asked to score the presence of morphological features for each nodule referring to density distribution (homogeneous, inhomogeneous, high, low), lesion margin (spiculation, lobulation, demarcation by interlobular septa, sharply-defined, ill-defined), lesion surrounding (distortion of the surrounding parenchyma, pleural/fissure retraction, attachment to pleura, fissure or vessel) and lesion architecture (thickened wall of a bulla, bubbles, air bronchogram). Separately per observer and feature, chi square analysis was used to determine the power to discriminate between benign and malignant nodules. Further studies will show whether integration of more morphological features will increase the power of risk prediction. Screened patients referred from outside our institution were excluded due to limited follow-up. Patients with negative, benign, or probably benign results were recommended to have a repeat screening exam in 6-12 months. Patients with suspicious findings were recommended to undergo a pulmonary consultation. To be considered compliant, patients had to be no more than 90 days past due for their next recommended exam or clinical evaluation as of 9/12/2014. Patients who died, were diagnosed with cancer, exceeded the program age limit, or became otherwise ineligible for additional screening were considered adherent. The most common reasons for non-compliance were refusal to undergo the follow-up exam (66. Subgroup analysis demonstrated a statistically significant increase in screening compliance among female patients (p = 0. Concerning patient volumes, 14 of 17 (82%) sites reported that the number screened was stable to increased over the past 3 to 6 months, and substantially fewer sites scan ≤5 patients per week compared to prior years (29% in 2015; 74% in 2014; and 87% in 2013). Regarding charges, a self-pay model was used exclusively at only 1 of 17 sites (6%) in 2015, a decrease from 47% in 2014. Concerning solid nodule size thresholds for defining a positive screen, 12 of 17 sites (71%) now use ≥6 mm, an increase from 11% in 2014. Nearly half of all sites (8 of 17, 47%) have introduced local training and/or credentialing policies for participating radiologists. Only 1 site uses software for volumetric nodule measurement and computer aided detection, whereas 5 of 17 (29%) sites use data management software for tracking patient data. Graduates of radiology residency are now board eligible and have the challenge of preparing for this exam while also being in a new work environment. Perspectives on preparing for the exam during fellowship and while practicing in an academic center will be discussed. Perspectives on preparing for the exam while starting a private practice job will be discussed. Ultimately, the most convincing reason to prioritize these skills is the importance that they play in our everyday life as Radiologists and Radiologists-in-training. In this session, we will review noninterpretive skills and share practical tips on how to teach and assess these essential skills. These provide a new method for tissue characterization and can be used to aid diagnosis and for monitoring treatment. Examples relating to cardiac imaging in include acute myocardial infarction, myocarditis, amyloid and Fabry disease. When used following the administration of gadolinium contrast, T1 maps can be used to calculate the extracelluar volume maps of myocardium. All specimens were examined with plain film radiography to exclude advanced degenerative arthrosis, prior osseous injuries as well as joint replacement. It appeared as a thin black structure on T1 weighted sequences and was best visualized on coronal images. Information concerning this structure may be crucial with respect to the diagnosis and understanding of knee pathologies. The anterolateral tibial traction contusion was characteristically subcortical, elongated (mean size (mm) 10.

Monitoring of radical scavenging actvity of peroral administraton of the Kampo medicine Sho-saiko-to in rats gastritis burning stomach discount pariet master card. A pilot study on the efects of thymus protein on elevated Epstein-Barr virus tters in human subjects erosive gastritis definition buy 20mg pariet free shipping. Combinaton therapy with thymosin alpha1 and interferon for the treatment of chronic hepatts C infecton: a randomized gastritis en ninos order pariet online, placebo-controlled double-blind trial gastritis fiber discount pariet 20mg without a prescription. Risk Factors for Hepatitis C infecton, although the virus is not transmited very efciently by sex. Caring Ambassadors Hepatitis C Choices: 4th Edition include use of barrier methods. For women with more advanced liver disease (such as those with signifcant bridging fbrosis or cirrhosis), complicatons of liver decompensaton may occur during pregnancy, especially if there is evidence of portal hypertension prior to pregnancy. Women with advanced stages of fbrosis should seek expert medical advice regarding the risks of pregnancy prior to concepton. There are no preventatve therapies available to interrupt transmission between mother and infant. Longer duration of membrane rupture7, 8, invasive fetal monitoring7, and volume of blood loss ≥500g during the delivery have been reported as possible factors contributing to mother-infant transmission. The majority of studies report no difference in mother-infant transmission by route of delivery, including studies evaluating elective cesarean sections versus emergency cesareans and vaginal delivery. For this reason, it is recommended that testng of infants be delayed untl age 12 to 18 months. These complicatons develop over several decades of infecton and do not occur in all infected persons. Higher estrogen states during a women’s life occur during pregnancy and with use of oral contraceptve or hormone replacement therapy. Studies fnd that women that have had one or more pregnancies have less fbrosis in their liver than women who have never been pregnant. This associaton was not as strong as that found with pregnancy, but stll follows the same patern that higher states of estrogen maintained during a lifetme are associated with less liver damage. The risk of progressive liver damage or fbrosis increases afer women reach menopause. Replacement of estrogen through hormone replacement therapy in menopause has been associated with a decrease in the rate of progression and a lower risk of cirrhosis. Women that used hormone replacement therapy or estrogen therapy early in menopause were shown in studies to have a lower rate of fbrosis in their liver than women that did not partcipate in any hormone therapy. However, the diference in risk between men and women decreases once women reach menopause. This suggests that estrogen may be protectve against the development of liver cancer. Caring Ambassadors Hepatitis C Choices: 4th Edition y As with the risk of cirrhosis, studies show that women with a higher lifetime of estrogen were at less risk of developing liver cancer. However, the body starts decreasing its producton of estrogen and progesterone several years before menses stop. As discussed above, there are studies that show hormone therapy replacement is associated with a decrease in the progression of fbrosis as well as the risk of liver cancer. Regular alcohol usage can cause contnuous damage to the liver, resultng in the development of progressive fbrosis and eventually cirrhosis. Drinking on average more than two alcohol beverages per day increases the risk of cirrhosis to a signifcant degree. Relatve risk estmated for the development of alcohol induced liver disease based upon sex and consumpton of alcoholic beverages per week. Relatve risk estmated for the development of alcohol induced cirrhosis based upon sex and consumpton of alcoholic beverages per week. This may increase the concentration of alcohol byproducts that can damage the liver. If alcohol is used, it is recommended that no more than 1 drink per day be consumed. Excessive weight can cause a collecton of fat to build up in the liver, a conditon called steatosis. The body type that accumulates fat centrally has been described as “apple” shaped. Figure 3 shows the diferences between more central fat storage (apple shaped) and more generalize a spread over the body (pear shaped). People with a “pear” body type (right) carry fat more below the waist in the hips, butocks, and legs. Obesity and steatosis in the liver can interfere with the efectveness of hepatts C treatment. With obesity, there is a greater body mass and this may reduce the amount of drug available in the body and impair the efectveness of treatment. Optmizaton of weight is an important issue 263 Copyright © 2008, Caring Ambassadors Program, Inc. Data demonstrate that steatosis and infammaton in the liver can be reduced with even modest weight loss. Being at a healthy weight is important to prevent many diseases and to improve quality of life. These medicatons work by trying to stop the virus from entering into the liver cells and from making copies of themselves. The medicaton can also cause a decrease in blood cell counts, both red blood cells (anemia) and white blood cells (neutropenia). With the medication causing a decline in these counts, women can experience these symptoms earlier in treatment and more severely than men. However, antviral therapy prior to pregnancy results in delays in the tme to concepton, and treatment is successful in at best a variable proporton of those treated. Most importantly, treatment cannot be taken during pregnancy or when breasteeding. Chapter 18: Women and Hepatitis C Ribavirin is teratogenic (causes birth defects in the fetus) and its use in women and in their partners trying to conceive and in those pregnant is absolutely contraindicated. The efects of ribavirin are prolonged and it is necessary to wait six months afer the last dose of ribavirin before trying to conceive. However, if a woman does drink, her intake should be a maximum of 1 drink per day. Faty Liver (Steatosis) y Excess weight can lead to fat in the liver, which increases inflammation and liver damage. Hepatts C Treatment y Some studies suggest that women have a higher likelihood of achieving a sustained viral response to interferon based therapy. Obstetric risks and vertcal transmission of hepatts C virus infecton in pregnancy. A signifcant sex-but not electve cesarean secton-efect on mother-to-child transmission of hepatts C virus infecton. Re-evaluaton of the true rate of hepatts C virus mother-to-child transmission and its novel risk factors based on our two prospectve studies. Clinical features and progression of perinatally acquired hepatts C virus infecton. Progression of liver fbrosis in women infected with hepatts C: long-term beneft of estrogen exposure. Liver fbrosis in women with chronic hepatts C: evidence for the negatve role of the menopause and steatosis and the potental beneft of hormone replacement therapy. Role of reproductve factors in hepatocellular carcinoma: Impact on hepatts B and C-related risk. Liver functon in postmenopausal women on estrogen-androgen hormone replacement therapy: a meta analysis of eight clinical trials. Predicton of risk of liver disease by alcohol intake, sex, and age: a prospectve populaton study. Is nutrient intake a gender-specifc cause for enhanced susceptbility to alcohol-induced liver disease in women? Variaton in ethanol pharmacokinetcs and perceived gender and ethnic diferences in alcohol eliminaton. Sex-related liver injury due to alcohol involves actvaton of Kupfer cells by endotoxin. Drinking habits of subjects with hepatts C virus-related chronic liver disease: prevalence and efect on clinical, virological and pathological aspects.

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In the early medieval centuries gastritis natural treatment pariet 20 mg for sale, Byzantium and the Lev­ ant were far more medically developed than Latin Europe chronic gastritis nsaids purchase pariet cheap. In the Christian West gastritis neurological symptoms cheap pariet on line, provision of hospitals expanded from the twelfth cen­ tury with the growth of population gastritis diet purchase pariet 20 mg otc, trade, and towns. Medieval hospitals remained frequently associated with a church or monastery, and life within them the Hotel Dieu, a large hospi­ tal for the poor in Paris. From the high Middle Ages, hospi­ tals became common in the growing cities of Europe. Almost without exception they were religious founda­ tions, set up for pious purpos­ es and staffed by male and female members of religious orders. Their functions were primarily to care for the sick, the old, the lame, and for oth­ ers in need of shelter. They would ensure a pious passing for the dying: specifically medical aims and functions were secondary. It was more important to ensure that patients died in a state of grace, having received the sacraments, than to attempt heroic medical treatments to prolong temporal life. In medieval England and throughout the rural parts of continental Europe, hospices routinely provided care and hospitality for the indigent, elderly, infirm, and for pilgrims, without pre­ dominately being devoted to the sick. A high wall would separate the leprosary from the community, while small huts within provided shelter for the sick. As leprosy declined, the leprosaria were used for persons sus­ pected of carrying infectious diseases, the insane, and even the indigent. Thus the Hopital des Petits Maisons near the monastery of St Germain des Pres outside Paris, which began as a leprosarium, was later used for indigent syphilitics and disordered pilgrims. St Giles in the Fields, west of the walls of London, was originally a leprosarium. When bubonic plague struck Europe in the fourteenth century, the leprosaria were requisitioned as the first plague hospitals. Lazarettos (named after the pro­ tective patron, St Lazarus) began to be built in the later years of the century, to safeguard trade and to protect city populations. The first documented pesthouse was built at Dubrovnik (Ragusa) on the Adriatic coast of Croatia in 1377, fol­ lowed by an infirmary in Marseilles in 1383. Venice built two lazarettos on islands of its lagoon in 1423 and 1468, respectively. Milan completed a pesthouse 20 years later, and the hospital of St Sebastian, built in Nuremberg in 1498, became the model for later German plague hospitals. A seventeenth-century pest house or lazaretto, with its gates and guard, in Rome. Named after the biblical Lazarus, lazarettos were origi­ nally designed to house lepers well out of harm’s way. With the decline of leprosy in Europe from around the thir­ teenth century, lazarettos increasingly became requisi­ tioned as pesthouses in times of plague. In either case, their crucial function was to pro­ tect the rest of the population. Hospitals and Surgery 211 It was in Italian cities Venice, Bologna, Florence, Naples, and Rome that the Interior of the hospital of S. In the building is still used as a Italian urban centres, hospitals played a key part in caring for the poor and sick. Notice the Religious confraternities took upon themselves the duty of charity, and some priest. Severe plague outbreaks and other epidemics spurred the viduals may well be patrons foundation of hospitals, so that by the fifteenth century there were thirty-three and benefactors who would expect to be included in such hospitals in Florence alone roughly one for every 1,000 inhabitants. The size of a painting, which displays these varied enormously, from under ten beds to 230 at S. These Florentine hospitals were primar­ the altercation between the ily for orphans, pilgrims, widows, and the teeming poor; only seven were princi­ cat and dog supposedly pally dedicated to the sick, but these did have medical staffs attached to them. Maria Nuova there were six visiting physicians, a surgeon, and three junior staff physicians and surgeons. In England, there were about 470 ‘hospitals’ by the close of the fourteenth cen­ tury, but they were generally tiny and barely medical. Numbers of inmates varied from around two or three to about thirty, with an average of about ten. St Thomas’s and St Bartholomew’s expanded as hospitals for the sick poor, and Bethlem catered for the mad (see page 288). Nevertheless, although Stuart London grew into a mon­ ster city it had over half a million people by 1700, making it, with Paris, the largest city in Europe it had just two medical hospitals of any consequence. And beyond the capital, there were no medical hospitals at all in England in 1700. Religious and lay elements in the hospitals generally worked well Visitors to a hospital. Bas together, although conflicts sometimes arose between physicians, with their med­ relief in enamelled terracotta ical priorities, and the nursing staff, with their pious ends. Charitable donations by Giovanni della Robbia at to hospitals played a part in local chains of protection, patronage, and family the Ceppo Hospital, Pistoia, first half of the sixteenth power. In France, the hopital general (similar to the English poorhouse) emerged century. The Hotel Dieu in Paris was more specifically designed as a healing institu­ tion; this was run by religious orders. In the time-honoured manner, the Vienna hospital sheltered the poor as well as providing medical facilities for the sick. Planned for 1,600 patients, it was divided into six medical, four surgical, and four clinical sections; eighty-six clinical beds met the teaching needs of its medical staff. New infir­ maries were also set up in other German-speaking territories, including the Juliusspital at Wurzburg (1789), which won praise for its operating theatre. Hospitals and Surgery 213 Berlin’s Charite Hospital was built in 1768, and, in the Ukraine, Catherine the Great (1762-96) erected the huge Obukhov Hospital. Although by European standards early-modern England was exceptionally ill-endowed with hospitals and also with sister institutions such as orphanages this lamentable state of affairs changed rapidly in the Age of Enlightenment when philanthropy, secular and religious, raised many new foundations. The new hospitals founded in eighteenth-century England were meant for the poor (although not for parish paupers, who would be dealt with under the Poor Law). Granting free care to the respectable or deserving sick poor would, it was hoped, confirm social ties of paternalism, deference, and gratitude. To the metropolis’s two ancient hospitals, a further five were added between 1720 and 1750: the Westminster (1720), Guy’s (1724), St George’s (1733), the London (1740), and the Middlesex (1745). They stirred the founding of institutions in the provinces, where no genuinely medical hospitals had existed at all. The Edinburgh Royal Infirmary was set up in 1729, followed by hospitals in Winchester and Bristol (1737), York (1740), Exeter (1741), Bath (1742), Northampton (1743), and some twenty oth­ ers. Traditional cathedral and corporation cities came first, industrial towns, such as Sheffield and Hull, fol­ lowed. Augmenting these general foundations, humanitarians also pumped money into specialist institutions for the sick. St Luke’s Hospital was opened in London in 1751, making it at that time the only large public lunatic asylum apart from Bethlem. Unlike Bethlem, criticized for its barbarity (see page 296), St Luke’s was launched to an optimistic fanfare, its physician, William Battie, asserting that, if handled with humanity, lunacy was no less curable than any other disease. By 1800, other great towns such as Manchester, Liverpool, and York had public lunatic asylums, philanthropically supported. Alongside lunatics, sufferers from venereal disease also became objects for charity surely a sign of a changing cli­ mate of opinion: the harsh religious judgement that such diseases were salutary punishment for vice was evidently on the wane, being supplanted by the Enlight­ enment view that relief of suffering was the duty of humanity. It was paralleled by another London charitable foundation, the Magdalene Hospital for Penitent Prostitutes (1759) less a medical hospital than a refuge where harlots wishing to go straight were taught a trade. In London, the earliest maternity hospitals were the British (1749), the City (1750), the General (1752), and the Westminster (1765). They also enabled unmarried mothers, mainly servant girls, to deliver their illegitimate babies with no questions asked.

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Under these laws chronic gastritis fever cheap pariet 20mg without prescription, an offender must receive a life sentence or a multi-decade prison term if he has been convicted of a specified number of predicate felonies or “strikes gastritis diet order pariet with visa. As originally enacted gastritis diet generic 20 mg pariet with mastercard, the law required a minimum sentence of 25 years to gastritis diet 20mg pariet with mastercard life for a felony conviction where the offender had at least two prior serious or violent felony convictions, even if the current felony was neither serious nor violent. Many used the incident and the ensuing public fear to their political advantage, making “three strikes” the catchphrase of choice during the 1994 campaign. One state senator confessed, “I don’t think we have any choice [but to pass it],” while another candidly admitted, “I’m going to vote for these turkeys because constituents want me to. Some of these laws have created or toughened mandatory minimums in the wake of horrifying crimes against sympathetic victims. These statutes can be both well-intentioned and shortsighted, as lawmakers respond to shocking fact-patterns by enacting overly broad sentencing provisions without considering the ultimate consequences. In 1994, for instance, Congress created a so-called “safety valve” in recognition that, for some offenders “who most warrant proportionally lower sentences” and “are the least culpable” by definition, “mandatory minimums generally operate to block the sentence from reflecting mitigating factors. In the new millennium, there have been even more promising signs for those who oppose mandatory minimums. In August 2010, President Obama signed into law the Fair Sentencing Act, which reduced the sentencing disparity between crack and powder cocaine offenses. Mandatory Minimums 123 time a federal mandatory minimum had been repealed since the Nixon administration—and it reduced the crack/powder disparity, from 100:1 to 18:1, by upping the required amount of crack cocaine to trigger a mandatory sentence. At a policy level, the Justice Department issued memoranda instructing federal prosecutors that they need not always seek the harshest possible sentences;25 that they should avoid excessive mandatory penalties for low-level, nonviolent drug offenses;26 and that prosecutors should not use a recidivist enhancement to extract plea bargains. Since the turn of the millennium, some two dozen American jurisdictions have enacted some kind of reform to their mandatory minimum laws. With a few exceptions, California’s three-strikes statute now requires a sentence of 25 years to life only when a defendant’s current conviction is for a serious or violent 24. In other words, it now takes 28 grams of crack cocaine to trigger a 5-year mandatory sentence and 280 grams of crack cocaine to generate a 10-year mandatory sentence. Dep’t of Justice, to All Federal Prosecutors, Department Policy on Charging and Sentencing (May 19, 2010). Dep’t of Justice, to the United States Attorneys & Assistant Attorney General for the Criminal Division, Department Policy on Charging Mandatory Minimum Sentences and Recidivist Enhancements in Certain Drug Cases (Aug. Dep’t of Justice, to Department of Justice Attorneys, Guidance Regarding § 851 Enhancements in Plea Negotiations (Sept. For a discussion of clemency and its reform, see Mark Osler, “Clemency,” in the present Volume. The Three Strikes Reform Act also allows a court to reduce the term of imprisonment for an inmate sentenced under the prior regime but whose third strike was not a serious or violent felony. The political norm that favors more crimes and harsher punishments, including mandatory minimums, may turn out to be a mile wide but only an inch deep. In fact, we may be reaching a tipping point in criminal justice as evidenced by the growing ranks of reform advocates. As mentioned at the outset, however, it may still be possible to paint a legislator who votes to repeal mandatory minimums as being “soft on crime. Consequentialist theories are forward-looking, concerned with the future consequences of punishment. Nonconsequentialist theories are backward-looking, interested solely in past acts and mental states. When it comes to mandatory minimums, discussion of these theories is not merely an academic exercise. Punishment philosophy informs the practice of sentencing, as codified in the penal law or administered by criminal justice actors, and the transition from theory to practice can produce troublesome consequences in the real world. Scholars have suggested that mandatory minimum sentences are part of “ominous trends in our penal practices,”31 stemming, at least in part, from politicians co-opting punishment theories to rationalize seemingly irrational punishment systems. Dep’t of Justice, to All Federal Prosecutors, Department Charging and Sentencing Policy 1 (May 10, 2017). Under this theory, moral blameworthiness may be seen as a function of an offender’s subjective state of mind, the wrongful nature of his acts, and the harm he has caused. Retributivism thereby incorporates limiting principles on systems of criminal justice. Among other things, penalties must be based on the depravity of the offense and not merely the danger posed by the offender. Retributivism does not advocate disproportionate punishment based on a heightened risk of recidivism alone. More generally, all theories of retribution require that punishment be proportionate to the gravity of the offense, and any decent retributive theory demands an upper sentencing limit. In measuring the gravity of an offense for proportionality analysis, one might look to, among other things, “the harm caused or threatened to the victim or society. According to proponents of mandatory minimums, those who are sentenced under these laws—purportedly, high-level offenders who perpetrate violent and serious crimes—can only be assured of receiving their just deserts through 32. See Mandatory Minimum Sentencing Provisions Under Federal Law: Hearing Before the U. Few retributivists would balk at a life sentence for a serial murderer, for instance, and most mandatory minimums imposed for serious crimes of violence. In enacting such statutes, lawmakers tend to imagine an exceptionally serious offense and set the mandatory minimum they consider fitting for a particularly egregious offender. But they do not take into consideration a far less serious crime or less culpable criminal who nonetheless might be sentenced under the law. For this reason, mandatory minimums are unaffected by proportionality concerns and can pierce retributive boundaries with excessive punishment. Consider, for instance, the problems that have arisen under certain recidivist laws, where an offender must receive a life sentence or a multi-decade prison term if he has been convicted of a specified number of predicate felonies. Such a lengthy sentence for sometimes trivial offenses—life imprisonment for a three-time nonviolent larcenist,40 for instance, or a 25-year to life sentence for petty theft by a recidivist41—proves almost impossible to reconcile with traditional conceptions of retribution. In very discrete situations, the crime’s low predicates of any drug and a firearm, and the high penalties that ensue—a 5-year mandatory sentence for the first count and 25-year sentences for each subsequent count—might be justifiably employed against, say, a brutal drug lord or the occasional dictator who turns his country into a narco-state. But when applied to the vast majority of offenders, low-level drug dealers who neither threaten violence nor cause injury, the results can be grotesque. In one § 924(c) case, for instance, a defendant received a 55-year term of imprisonment for low-level marijuana distribution while possessing (but not brandishing or using) a firearm. Mandatory Minimums 127 In fact, the sentence was more than twice the federal sentence for a kingpin of a major drug-trafficking ring in which a death results, and more than four times the sentence for a marijuana dealer who shoots an innocent person during a drug transaction. The primary consequentialist theory—utilitarianism—imposes criminal penalties only to the extent that social benefits outweigh the costs of punishment. In particular, the imposition of criminal sanctions might: discourage the offender from committing future crimes (specific deterrence); dissuade others from committing future crimes (general deterrence); or disable the particular offender from committing future crimes (incapacitation). With respect to deterrence, mandatory minimum sentences are sometimes justified as sending an unmistakable message to criminals. They argue that because of the wide diversity of views on the appropriate level of punishment for offenders, legislators—not judges—are in the best position to make sentencing determinations. In the interest of full disclosure, I served as appellate counsel in the Angelos case and assisted in efforts to achieve Mr. Another utilitarian goal is rehabilitation, that punishment can reform a particular offender against committing future crimes. As far as I know, no plausible argument has been made that mandatory sentencing serves rehabilitation. Rather, imprisonment either has no effect on an inmate’s future offending or perhaps even increases recidivism. They may also be at risk of reoffending because of imprisonment’s social and economic consequences, such as the difficulties of obtaining gainful, lawful employment after release. Shepherd,Fear of the First Strike: the Full Deterrent Effect of California’s Two and Three-Strikes Legislation, 31 J. For a refutation of these findings, see, for example, Tonry, Mostly Unintended Effects, supra note 1, at 99–100. As discussed below, any incapacitative benefit from mandatory minimums is likely to be modest and outweighed by other considerations.

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