Congenital posterior urethral diverticula causing bladder outlet obstruction in a young male

We present a case of 26-year-old male presenting with mild renal failure. Ultrasound findings were suggestive of posterior urethral valve, but micturating cystourethrogram and endoscopic evaluation confirmed the diagnosis of posterior urethral diverticulae. Transurethral resection of diverticulae was performed. Patient is voiding well and his renal function has stabilized.

Commentary: Jail-based competency restoration

Many factors influence restoration of competence to stand trial: age, IQ, severity of mental illness, criminal history, treatment history, and others. This commentary poses the question of whether competency to stand trial is also influenced by the setting in which restoration treatment occurs. Jail-based competency-restoration programs, which are in their infancy and have yet to produce large-scale data demonstrating their efficacy, are examined. Several factors related to jail-based restoration are considered: choosing the right candidates for the program, impact of treatment in a punitive setting, ability to maintain separation between treaters and forensic evaluators, procedures for involuntary medication, aggregation of incompetent defendants in regional jails, effect on malingering, and cost savings.

Ethics in forensic psychiatry publishing

Several organizations have developed guidelines to help authors and editors of medical journals negotiate ethics dilemmas in publishing, but very little is known about how these guidelines translate to the context of forensic psychiatry. In this article, we explore the important topic of ethics in forensic psychiatry publishing. First, we review the historical development of ethics principles in medical and psychiatric publishing. We then analyze eight ethics dilemmas that have arisen in the publication of The Journal of the American Academy of Psychiatry and the Law (The Journal) from 2000 to 2009, including disputes about authorship, conflict of interest, redundant publication, bias in peer reviewers, confidentiality in case reports, and others. We identify ethics principles that were relevant to the dilemmas and discuss how they were resolved by the editors of The Journal. We conclude by using the principles identified in the practical resolution of ethics dilemmas to derive a conceptual foundation for ethics in forensic psychiatry publishing.

Quadruple malignancy in a single patient: a case report and comprehensive review of literature

The occurrence of multiple primary malignant neoplasias (MPMN) is a rare but increasingly frequently reported event. Many theories have been proposed to explain MPMNs, but none have been proven. The key risk factors appear to be smoking and family history. While numerous studies have been published on the development of second malignancies following a first primary, the literature contains only few case reports and reviews of patients with three or more malignancies. We report a case of a young female who, over a period of 30 years, developed four different malignancies and was treated radically on each occasion.

Polymorphisms in the vitamin D receptor and the androgen receptor gene associated with the risk of urolithiasis

Transcriptional activity of the vitamin D receptor (VDR) gene is regulated by androgen receptor (AR) gene and both are associated with renal stone formation. We examined gene polymorphisms of VDR (PCR-RFLP) and AR (GeneScan analysis) in 125 stone formers and 150 controls from north India. Genotype Ff of Fok-I and Tt of Taq-I demonstrated significantly higher risk (P<0.001, OR=3.559 and P=0.019, 1.830 respectively). Variant f allele exhibited 1.7-folds higher risk. Ff of Fok-I and Aa of Apa-I gene polymorphism showed higher risk in males only. Mean CAG repeat was significantly higher in hypercalciuric patients as compared to normocalciuric (mean=21.62 ± 3.384 vs. 20.11 ± 3.182; P=0.034). Combined effects 1.8-folds higher risk in patients with Tt genotype of Taq-I and short CAG repeat. Thus, association of FokI and TaqI VDR gene polymorphisms suggest VDR as an important genetic marker for urolithiasis. Further, patients with combination of Tt of Taq-I and short CAG repeat were at higher risk for stone formation.

Forensic evaluations and mandated reporting of child abuse

Statutes requiring physicians to report suspected cases of child abuse create a potential conflict for psychiatrists working in the forensic setting. What happens in the case in which a forensic psychiatrist, during the course of an evaluation requested by a defense attorney, learns about child abuse perpetrated by the evaluee? A complicated legal, ethics-related, and interpersonal dilemma emerges. Reporting the abuse may contribute directly to further legal harm to the evaluee and place a strain on the relationship with the attorney. However, not reporting the abuse potentially involves ignoring a legal mandate and risking further harm to a child. This article first reviews mandated reporting statutes across the states. Next, the arguments for and against reporting are outlined. Existing solutions to the problem are reviewed, and several alternative solutions are explored. Finally, an approach to negotiating the dilemma that can be used by forensic psychiatrists in practice is suggested.

Commentary: on doctors and lawyers

Psychiatrists and attorneys often find collaboration difficult, even when working toward mutually beneficial goals. In this commentary, a young psychiatrist reflects upon the mismatch between physicians and attorneys. Differences in medical and legal training, as well as different personality styles and approaches to problem solving, may contribute to conflict. However, psychiatrists can benefit and learn from the attorneys' approach and apply it to situations in which advocacy for good patient care and the fundamental values of medicine is necessary.

Comparison of asthma knowledge, management, and psychological burden among parents of asthmatic children from rural and urban neighborhoods in India

INTRODUCTION

Asthma prevalence is increasing in developing countries such as India. Little is known on parental knowledge of asthma severity, management and psychosocial impact, particularly among rural dwellers. Further, it is not known whether the female asthmatic child is particularly vulnerable.

OBJECTIVE

To evaluate parental asthma knowledge and psychological impact of having an asthmatic child.

METHODS

134 consecutive caregivers were surveyed at the visit for their child's asthma exacerbation at an urban hospital in Kanpur, India between 3/2007-3/2008.

RESULTS

The child's age range was 5.7A +/- 2.7 years. 76% were urban city dwellers with significantly higher number having a college degree. 23% children had moderate to severe persistent asthma; however, only 42% were on inhaled steroids. Parental severity perception was comparable to National Heart, Lung and Blood Institute (NHLBI) classification. While 67% identified bronchoconstriction occurred with asthma, only 8.9% recognized that inflammation played a role. There was no difference in the perceived stress by area of residence with 89% reported not or only sometimes feeling stressed with having an asthmatic child. Similarly, the concern among those with a female asthmatic child did not differ with 73% of caregivers believing that asthma would not affect their daughter's future.

CONCLUSION

In an urban Indian hospital, 23% of asthmatic children had moderate to severe persistent asthma but only 9% were on controllers. Their parents were well educated, able to identify asthma severity appropriately and denied being stressed with having asthmatic children, irrespective of the gender of the child. However, their understanding of asthma pathophysiology was sub-optimal. Increased disease knowledge may lead to greater medication adherence among asthmatic children in India.

Proof of concept studies for tissue-protective agents in multiple sclerosis

BACKGROUND

There is considerable interest in tissue-protective treatments for multiple sclerosis (MS).

METHODS AND OBJECTIVES

We convened a group of MS clinical trialists and related researchers to discuss designs for proof of concept studies utilizing currently available data and assessment methods.

RESULTS

Our favored design was a randomized, double-blind, parallel-group study of active treatment versus placebo focusing on changes in brain volume from a post-baseline scan (3-6 months after starting treatment) to the final visit 1 year later. Study designs aimed at reducing residual deficits following acute exacerbations are less straightforward, depending greatly on the anticipated rapidity of treatment effect onset.

CONCLUSIONS

The next step would be to perform one or more studies of potential tissue-protective agents with these designs in mind, creating the longitudinal data necessary to refine endpoint selection, eligibility criteria, and sample size estimates for future trials.

Hemangiopericytoma: an unusual cause of peritoneal carcinomatosis

Hemangiopericytoma, a rare mesenchymal tumour, is believed to originate from the pericyte of Zimmermann. It may affect every organ in the body. Recurrences after treatment and metastasis are well known. However, presentation of hemangiopericytoma with peritoneal carcinomatosis is not documented in literature. To the best our knowledge, we report the imaging findings of the first histologically proven case of hemangiopericytoma with peritoneal carcinomatosis.

Different white matter lesion characteristics correlate with distinct grey matter abnormalities on magnetic resonance imaging in secondary progressive multiple sclerosis

Background

Although MRI measures of grey matter abnormality correlate with clinical disability in multiple sclerosis, it is uncertain whether grey matter abnormality measured on MRI is entirely due to a primary grey matter process or whether it is partly related to disease in the white matter.

Methods

To explore potential mechanisms of grey matter damage we assessed the relationship of white matter T2 lesion volume, T1 lesion volume, and mean lesion magnetisation transfer ratio (MTR), with MRI measures of tissue atrophy and MTR in the grey matter in 117 subjects with secondary progressive multiple sclerosis.

Results

Grey matter fraction and mean grey matter MTR were strongly associated with lesion volumes and lesion MTR mean ( r = ±0.63–0.72). In contrast, only weak to moderate correlations existed between white matter and lesion measures. In a stepwise regression model, T1 lesion volume was the only independent lesion correlate of grey matter fraction and accounted for 52% of the variance. Lesion MTR mean and T2 lesion volume were independent correlates of mean grey matter MTR, accounting for 57% of the variance.

Conclusions

Axonal transection within lesions with secondary degeneration into the grey matter may explain the relationship between T1 lesions and grey matter fraction. A parallel accumulation of demyelinating lesions in white and grey matter may contribute to the association of T2 lesion volume and lesion MTR with grey matter MTR.

Grey matter magnetization transfer ratio independently correlates with neurological deficit in secondary progressive multiple sclerosis

Although there is substantial brain grey matter pathology in secondary progressive multiple sclerosis (MS), there has been limited investigation of its contribution to disability.This study investigated the correlation of magnetization transfer ratio (MTR) measures taken from brain grey matter, normal appearing white matter (NAWM) and lesions with neurological deficit and disability in 113 people with secondary progressive MS. In order to adjust for the potential effects of focal white matter lesions and global brain atrophy, T2 lesion volume and normalized brain volume (NBV) were also calculated for each subject. Clinical measures included the expanded disability status scale (EDSS) and the multiple sclerosis functional composite (MSFC) scores. Linear regression analysis was used to assess the age- and gender-adjusted correlation of MTR histogram mean, peak height and peak location with the MSFC and individual component measures. Logistic regression analysis was used to determine whether imaging measures could be used to predict if subjects were in the higher disability group (EDSS > or = 6.5).Significant correlations were detected between MSFC composite and mean MTR in (i) normal appearing white matter (NAWM; r = 0.327, p < 0.0001), (ii) grey matter (r = 0.460, p < 0.0001) and (iii) lesions (r = 0.394, p < 0.0001). Although NBV and T2 lesion volume correlated significantly with MSFC, grey matter histogram mean emerged as the best predictor of MSFC score. None of the MRI measures significantly predicted higher EDSS.These results suggest that brain grey matter pathology plays an important role in determining neurological impairment. The apparent paucity of correlation between MRI measures and EDSS is likely to represent the relative insensitivity of the latter measure in this study group.