A classification of combined homicide-suicide: An update-Part I: Introduction and psychopathology.

A 1995 classification of combined homicide-suicide was based on the psychopathology of the perpetrator and the relationship between the perpetrator and the victim(s). A three-part model was proposed for the study and potential understanding of individual homicide-suicide acts. This triarchic model consisted of the concepts of ego weakness, stress, and vector, the vector representing the ideational component. Today, approaching a quarter of a century after this initial classification based on a review of the literature available then, a considerable volume of experience and investigative knowledge has been published advancing our knowledge of homicide-suicide. The present review updates and revises the original classification, retains the two-part, psychopathological and relational classification, and adds several categories. Because this updated classification is more expansive than the original, it is presented in three parts. Part I, the present article, provides the introduction to this classification and the classification of mental conditions that may attend homicide-suicide. Parts II and III will address intrafamilial and extrafamilial homicide-suicide, respectively, the two major divisions of the classification based on the relationship between the actor and the homicide victim(s). All three parts are integral to this classification and belong together.

A classification of combined homicide-suicide: An update-Part II: Intrafamilial homicide-suicide.

This Part II of the three-part presentation of the updated classification of combined-homicide published in the Journal of Forensic Sciences addresses intrafamilial homicide-suicides (H-Ss). Intrafamilial H-Ss in this classification includes all close relationships including dating and intimate partners, not just traditional family relationships, in contrast to extrafamilial H-Ss where the victim(s) of homicide are either strangers or in a more formal but nonintimate relationship with the actor. Intrafamilial H-Ss are further divided and classified as intimate partner, filicide, familicide, parricide, and siblicide H-Ss, respectively, and are typically so grouped in the literature.

A classification of combined homicide-suicide: An update-Part III: Extrafamilial homicide-suicide.

The subclassification of homicide-suicide into psychopathology and intrafamilial homicide-suicides having been presented in the foregoing Parts I and II, this Part III concerns extrafamilial homicide-suicides. Extrafamilial homicide-suicides are divided into adversarial, autogenic mass, cult, and terrorist homicide-suicides. Adversarial homicide-suicides involve a "formal" relationship between actor and homicide victims, further divided according to the role of the actor in their relationship as employee, current or former pupil/student as in school shootings, patient, and litigant. For comparison, school shootings were divided into those resulting in 10 or more homicide victims and those with fewer. The autogenic mass homicide-suicide, wherein victims are strangers to the actor, was heuristically bifurcated here depending on the number of homicide victims, 10 or more or fewer. As expected, the homicide-suicides with larger numbers of victims were more homogenous.

Renal Tumours Of Non-Clear Cell Histology; 10 Years' Experience In A Specialized Centre.

BACKGROUND: Non-clear cell renal cell carcinomas are uncommon renal tumours with diverse histologically and genetically defined entities. Due to limited clinical outcomes data, no standardized management approach can be offered to these patients. This study aimed to analyse outcomes of non clear cell renal cell carcinoma after surgical resection of localized renal tumours in our population. METHODS: Patients with renal tumours who underwent partial or radical nephrectomy at the Department of Urology, from January 2010 to December 2019 were identified and evaluated, in terms of prevalence, presentation, recurrence, and survival outcome. RESULTS: Non-clear cell tumours were found in one-fourth of the total number of nephrectomies performed during this period for renal cell carcinoma (RCC). The mean age was 50.48±14.76 years (range 18-89 years) with 57% being of the male gender. The predominant types were chromophobe RCC, papillary RCC, and sarcomatoid RCC, in all non-clear cell renal tumours. Mean Recurrence Free Survival (RFS) for all tumours was 75.26±2.7 months. The projected 5 years RFS of papillary RCC, chromophobe RCC and sarcomatoid RCC were 94.2%, 84.3% and 62.5% respectively. CONCLUSIONS: RCC of non-clear-cell histology depicts excellent survival in patients with localized renal tumours. Furthermore, sarcomatoid RCC has worse recurrence free survival followed by chromophobe RCC and papillary RCC, in our population subset.

Metastatic prostate tumor to testes: Sign of advance disease.

Prostate cancer is the second most common cause of mortality for males in the United States. Metastases may be present, typically in the axial skeletal region. To date, few patients have presented with metastases to the testicles. We present the case of an adult male with diagnosed prostate cancer who presented and subsequently diagnosed bilateral testicular metastases. Testicular metastases secondary to diagnosed prostate cancer are very rare. Patients present with these metastases may have unfavorable prognosis. This case demonstrates that prostate cancer may metastasize to rare locations such as the testes, requiring further surgical intervention.

Prevalence of Suicidal Behaviors in Residents of Long-Term Care Facilities: A Systematic Review and Meta-Analysis.

BACKGROUND: Long-term care facilities (LTC) plays a pivotal role in caring for geriatric population. However, the risk of suicide in long-term care institutions among older individuals is little understood (e.g., nursing homes, assisted living facilities). OBJECTIVE: The purpose of this systematic review is to pool and meta-analyze the data on prevalence of suicidal behaviors in geriatric population residing in long-term care facilities. METHODS: We have conducted the systematic review in accordance with the PRISMA guidelines. The utilized databases are Pubmed, Medline, Google scholar and Scopus. The Meta-analysis was done using OpenMeta [analyst] software. Subgroup analysis was also performed. RESULTS: After running an analysis on pooled data from twenty cross-sectional studies with 3,023,224 participants, the prevalence of suicidal behavior is 6.4% (95% CI = 5.7-7) in LTC. CONCLUSION: This meta-analysis shows pooled prevalence of suicidal behavior among geriatric residents of LTC was found to be moderately high all over the world.

Psychological and Psychiatric Comorbidities in Youth with Serious Physical Illness.

An estimated one in six children in the United States suffers from a mental disorder, including mood, anxiety, or behavioral disorders. This rate is even higher in children with chronic medical illness. This manuscript provides a concise review of the symptoms that comprise mental conditions often observed in children with chronic illness or at the end of life. It further provides some guidance to help clinicians distinguish normative from pathological presentations. Evidence-based psychotherapy interventions, potentially applicable to the acute inpatient setting, are briefly summarized. Broad recommendations are made regarding both psychotherapeutic as well as pharmacotherapeutic interventions, with a review of common or serious medication side effects. Finally, delirium recognition and management are summarized.

Prodromal depression and subsequent risk of developing Parkinson's disease: a systematic review with meta-analysis.

Aim: Parkinson's disease (PD) is a progressive neurological disorder that predominately affects dopaminergic neurons. We believe that this pooling of data will help to better understand the prodromal nature of depression in PD. Materials & methods: We conducted this study in accordance with PRISMA guidelines 2020. Fifteen eligible articles were shortlisted for final analysis. Risk of bias assessment was also conducted Results: The random-effect model revealed that the risk of subsequent PD in patients with prodromal depression was twice as likely (odds ratio, 2.04; 95% CI, 1.02-4.08) as compared with a healthy population. Conclusion: Our meta-analysis concluded that the subsequent risk of PD is significantly higher in patients with depression as compared with healthy individuals.

Parkinson's disease (PD) is a nervous system disease that predominantly affects neurons of the brain that controls voluntary movement and behavioral processes such as mood, reward, addiction and stress. There is a wide spectrum of problems that can present in patients with PD, however, there are few that can precede the beginning of the illness. Previous studies have evaluated the relation of psychiatric symptoms with PD. However, many aspects need to be studied to understand this relationship. The main emphasis of this systemic review is to establish the association of prodromal depression before the development of PD. Our study showed that there is a strong association between depression and PD and suggests an increased risk of developing PD in formerly depressed patients. Though, it is still unclear if depression is either an early prodromal symptom of PD or a causative risk factor for PD and warrants further studies to determine the causality relationship between the two.

Renal endometriosis: A benign disease with malignant presentation.

Endometriosis is a common gynecological disorder in which endometrial tissue is located outside the uterine cavity. Urinary tract involvement by endometriosis is uncommon. Renal endometriosis is a rare disorder and is not evident on imaging. It may be misdiagnosed as malignant disease and patients may undergo invasive procedures for it. We report a case of a young lady who presented with symptoms typical for renal mass, and was diagnosed as a tumor on imaging. Patient underwent radical surgery and histology revealed renal endometriosis.

Non-fasting OGTT versus Fasting OGTT for screening of Hyperglycaemia in Pregnancy (HIP).

OBJECTIVES: To compare the reliability of non-fasting oral glucose tolerance test (OGTT) versus fasting OGTT for screening of hyperglycaemia in pregnancy (HIP). METHODS: This cross sectional analytic study was conducted by the Department of Obstetrics & Gynaecology, Isra University Karachi Campus from October 2016 to April 2017. A total of 225 pregnant women irrespective of gestational age were included in the study. They underwent non fasting 75 grams OGTT. Venous plasma glucose was done 02 hours after the glucose load. Same women were advised to come again within three to seven days for fasting OGTT. Venous plasma glucose (VPG) was estimated in fasting and 2 hours post glucose load. RESULTS: Using the non-fasting OGTT, out of 204 women, 32 were diagnosed with hyperglycemia. All these 204 women were again called for fasting OGTT three to seven days after the initial non-fasting OGTT. Only nine were diagnosed with hyperglycemia, out of these nine women, seven women who were screen positive on non-fasting OGTT were found to be screen positive on fasting OGTT as well. However, only two women were additionally diagnosed with hyperglycemia who were initially screen negative on non-fasting OGTT. The non-fasting OGTT has diagnosed HIP with sensitivity of 77.7%, specificity of 87.1%, positive predictive value of 21.8% and negative predictive value of 98.8%. CONCLUSION: The use of the non-fasting OGTT at first antenatal visit may be a practical approach to detect the HIP as screening and diagnostic tool in the resource constrained settings.

Intraoperative flexible nephroscopy during percutaneous nephrolithotomy: An 8 years' experience.

OBJECTIVES: To see the effect of intra operative antegrade flexible nephroscopy during Percutaneous nephrolithotomy on stone free rate. METHODS: We retrospectively reviewed electronic medical records of patients who underwent percutaneous nephrolithotomy from 2010 to 2017 for renal stones >2cm. Patients found eligible were divided in, Group-I who did not have intraoperative Flexible nephroscopy and Group-II who had flexible nephroscopy during percutaneous nephrolithotomy. All procedures were done by senior consultants. Variables like Mean age, side, stone size, skin to stone distance and Hounsfield unit were compared. Outcomes like Stone free rate, hospital stay and operative time were compared between the groups. RESULTS: The study included 248 patients, consisting 85 (34.3%) females and 163 (65.7%) males. Mean age ± SD was 45.8±13.8 years. Both group were similar in characteristics like mean age, stone size, skin to stone distance and Hounsfield units. The overall stone free rate was 71%. It was not significantly different between the groups, 76% in Group-II vs. 67% in Group-I. However stone free rate markedly improved with flexible nephroscopy in patients with staghorn calculi. Mean operative time and hospital stay were similar between the groups. CONCLUSIONS: Intraoperative flexible nephroscopy during percutaneous nephrolithotomy significantly increases stone free rate in patients with staghorn stones.

Hemangioma of penile urethra - Treatment with intralesional triamcinolone.

Hemangiomas are benign vascular lesion, most commonly seen in liver and skin whereas rarely found in genitourinary system. In genitourinary tract urethral hemangiomas are mostly found in males. A case of uretheral hemangioma in 18 years old boy who presented with history of painless bleeding per urethra since age of 3 years. Cystoscopy revealed multiple sub centric lesions in anterior urethra distal to verumontenum. Patient was treated with cystoscopic fulguration using diathermy. He started bleeding again on 3rd postoperative day, so intralesional triamcinolone was given. On follow up at one and three months he was asymptomatic.

Acute Lobar Nephronia in an infant presented as a renal tumor.

A case report of a 02-month-old infant referred to us with incidental bilateral renal masses on ultrasound, which was reported as nephroblastoma/Wilms tumor on CT scan, no signs, and symptoms of infection. Urine and blood cultures were negative, which led to a percutaneous renal biopsy which showed Acute Lobar Nephronia. The infant was started intravenous antibiotics which resulted in the resolution of bilateral renal masses on serial ultrasounds.

Small-cell neuroendocrine carcinoma of the urinary bladder: A case report.

Primary neuroendocrine carcinomas of the urinary bladder are rare. A 60-year-old male presented with gross hematuria for the past 3 months. Diagnostic flexible cystoscopy revealed a papillary lesion above the right ureteric orifice. Transurethral resection of bladder tumor was performed and resected tissue was sent for histopathology that revealed high-grade urothelial carcinoma with small-cell neuroendocrine differentiation. Lamina propria, muscularis propria, and perineural invasion was seen which was later also confirmed by immunohistochemistry. The patient received neoadjuvant four cycles of chemotherapy and then underwent radical cystoprostatectomy with ileal conduit. The patient's recovery was uneventful and he is on regular follow-up from the past 12 months without any disease recurrence. Early detection and aggressive management can improve the survival and prognosis of these patients.

Pre-Ramadan health seeking behavior, fasting trends, eating pattern and sleep cycle in pregnant women at a tertiary care institution of Pakistan.

OBJECTIVE: To observe the pre-Ramadan health seeking behavior, fasting trends, eating pattern and, sleep cycle in pregnant women. METHODS: It is a cross-sectional observational study, from July to September 2017, conducted at Tertiary Care Hospital in Karachi. The tool used for data collection was interviewer based closed ended questionnaire, 279 pregnant women who fasted during Ramadan were included in the study. RESULTS: One to ten days of fasting was observed by 85.7% (198) of women. About 72.4% (202) never consulted any doctor for pre-Ramadan advice regarding fasting in pregnancy. Pregnant women 81.7% (228) believed that fasting would not cause any harm to their unborn child, while 42.7% (119) of family members feared about the health of mother and unborn child. Seventy four percent (208) of respondents had a reduced sleep cycle of about 3-4 hours. The food items consumed at Sehri and Iftar were rich in carbohydrates and fats. CONCLUSIONS: Pre-Ramadan medical consultation regarding safety of fasting during pregnancy should be structured and customized for women and their families. Gaps in knowledge identified in this study may help healthcare professionals to address these issues.

Postictal Mania Versus Postictal Psychosis.

PIM (postictal mania) or PIP (postictal psychosis) usually comes on after a single episode or a seizure cluster of generalized tonic-clonic or complex partial secondarily generalized seizures. Patients maintain a lucid interval of clear consciousness which precedes a psychotic episode. The symptoms may include insomnia, hallucinations, delusions, elated expansive mood, euphoria, and distractibility. We present a case of a 62-year-old male with PIP or mania preceding an episode of seizure. In the light of this case report, we illustrate the importance of being vigilant about the psychotic symptoms in a patient with epilepsy in order to minimize the morbidity.

Antenatal management of pregnancy complicated by diabetes.

The prevalance of Gestational Diabetes Mellitus (GDM) is increasing worldwide. It is estimated that 21 million women develop gestational diabetes out of which 1 in 7 births are affected. Women who have been previously diagnosed as GDM are at higher risk of developing diabetes in subsequent pregnancies and Type 2 Diabetes Mellitus (T2DM) later in life. Babies born to mothers with gestational diabetes also have a higher risk of developing type 2 diabetes in their teens or early adulthood. Instead of risk stratification universal screening is essential in all pregnant women. Tight glycaemic targets are required for optimal maternal and foetal outcome. This article outlines the importance of pre-pregnancy counseling, antenatal management, screening and treatment of Hyperglycaemia in Pregnancy (HIP).

A randomized comparative trial of early initiation of oral maternal feeding versus conventional oral feeding after cesarean delivery.

OBJECTIVE: To compare the effects of two maternal feeding policies-early versus conventional oral feeding-after cesarean delivery. METHODS: This prospective multicenter randomized comparative trial was conducted at tertiary care hospitals in Sindh, Pakistan, from 2010 to 2012. Women with an uncomplicated cesarean delivery under spinal anesthesia were allocated to an intervention of early (after 2 hours) or conventional (after 18 hours) initiation of oral feeding. Outcomes included maternal ambulation, maternal satisfaction, gastrointestinal functions, and length of hospital stay. RESULTS: In total, 1174 women (n=587 per group) were included in the final analysis. Gastrointestinal complications were not significantly different between the two groups. Lower intensities of thirst and hunger and a higher rate of maternal satisfaction were observed in the early feeding group (P<0.05), and 53.8% of women in this group were able to ambulate within 15 hours of surgery, compared with 27.9% of women in the conventional feeding group. The frequencies of readmission, febrile morbidity, and wound infection were insignificant. CONCLUSION: Early oral dietary initiation after cesarean delivery resulted in early ambulation, greater maternal satisfaction, and reduced length of hospital stay, with no detrimental outcomes, making this practice cost-effective. Hence, day-care cesarean delivery might be an option in resource-constrained settings. TRIAL REGISTRATION NUMBER: ChiCTR-TRC-13003651, http://www.chictr.org.

Diagnostic dilemma in Broad Ligament Leiomyoma with Cystic Degeneration.

UNLABELLED: Fibroids are smooth muscle benign tumors; most commonly arise from uterus but may also rise from extra uterine sites like broad ligament. This case report of broad ligament myoma with extensive cystic degeneration is presented for its rarity and diagnostic challenges as they mimic pelvic adenexal tumors. Mrs. X, 43 years old p5+2, asymptomatic women with no co-morbids presented with mass in abdomen. The MRI showed mix attenuation mass of 19.7 x 16.8 x 13.7cms arising from right side of uterus extending up to epigastrium, with cystic and solid components and ascitic fluid. Resection of mass with abdominal hysterectomy with bilateral salphingo oophrectomy was done. No local or abdominal organ metastases were seen. Histopathology showed left broad ligament leiomyoma weighing 4000 grams with cystic degeneration. CONCLUSION: Huge broad ligament leiomyoma with cystic degeneration and abdominal ascites may cause diagnostic dilemma with ovarian malignancy. This differential diagnosis must be considered before surgery.