First Cardiac Magnetic Resonance Experience in Bangladesh: A Case of Arrhythmogenic Right Ventricular Dysplasia.

Arrhythmogenic right ventricular dysplasia (ARVD) is a progressive degeneration and replacement of the right ventricular (RV) myocardial tissue by fat and fibrosis and produce clinical condition. Desmosome gene mutations are only the causative state for ARVD hereditary disorder. The arrhythmogenic right ventricular cardiomyopathy incidence is about 1/1000-5000. Mostly young people and athletes are bearing the clinical presentations include presyncope, syncope, ventricular tachycardias or ventricular fibrillation leading to cardiac arrest. We report about the first case of Cardiac magnetic resonance (CMR) imaging to diagnose a case Arrhythmogenic right ventricular dysplasia (ARVD) of a 34-year-old male from Savar, Dhaka, Bangladesh who was referred to cardiac emergency for the evaluation recurrent dizzy spells.

Electrosurgery Dissection versus Sharp Dissection: Effect on Early Postoperative Wound Complications in Modified Radical Mastectomy.

Modified radical mastectomy (MRM) is still the most commonly performed operation for breast cancer, despite the trends toward breast-conserving treatment. Since 1970s, electrosurgery (also known as electrocautery, diathermy) has been a widespread surgical tool to raise flaps and excise the breast specimen in order to perform a bloodless mastectomy. Use of diathermy has been well blamed for wound complications. To prevent undue delay in the adjuvant treatment, it is important to minimize the surgical complications. This quasi experimental study was conducted in the Department of Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh to evaluate the effects of electrosurgery and sharp dissection on early postoperative wound complications in MRM. 46 patients were included in the study (23 in each group). Data analysis done in SPSS version 23.0 and 'p' value <0.05 considered significant at 95% confidence interval. In Electrosurgery Dissection (ED) group mean duration of drainage was 7.8±1.2 days and in Sharp Dissection (SD) group 6.4±1.0 days (p value 0.000). Mean total drainage in ED group found 1082±287ml and in SD group 693±194ml (p value 0.000). Seroma formation found 7(30.4%) in ED group and 3(13.0%) in SD group (p value 0.004). Wound dehiscence found 5(21.7%) in ED group and 2(8.7%) in SD group (p value 0.013). Flap necrosis rate was 4(17.4%) and 1(4.4%) in ED and SD group respectively (p=0.003). Demographic and clinical variables were similar or differences were not statistically significant in two groups. No difference found in operating time and wound infection rate in two groups. The result of the study showed that, electrocautery dissection caused early postoperative wound complications more than the sharp dissection.

Needlestick injuries among Malaysian healthcare workers.

BACKGROUND: Needlestick injury (NSI) is a significant occupational health issue among healthcare workers (HCWs). AIMS: To determine the national self-reported incidence and risk factors for NSI among Malaysian Ministry of Health (MOH) HCWs. METHODS: Using data from the MOH national sharps injury surveillance programme, information on reported NSIs over a 1-year period (2016) for different HCW subgroups were extracted and analysed. RESULTS: A total of 1234 NSI cases were reported in 2016, giving an overall incidence of 6 injuries per 1000 HCWs. Medical doctors recorded the highest incidence (21.1 per 1000 HCWs) followed by dental staff (7.5), pharmacy staff (4.2), nurses (3.7), medical assistants (3.4) and allied and auxiliary staff (1.0). Doctors had significantly increased risk of NSI compared with allied and auxiliary staff (relative risk [RR] = 20.7, 95% confidence interval [CI] 15.5-27.5), medical assistants (RR = 6.1, 95% CI 4.5-8.2), nurses (RR = 5.7, 95% CI 5.0-6.6), pharmacy staff (RR = 5.0, 95% CI 3.7-6.6) and dental staff (RR = 2.8, 95% CI 2.2-3.5). Significant differences were found in age and sharps- handling experience between occupational subgroups (P < 0.001 for both variables). Male employees had higher risk than females (RR = 1.33, 95% CI 1.18-1.50), with a significant difference seen in their sharps-handling experience (P < 0.01). Important risk factors included unsafe practices such as recapping of needles and their improper disposal. CONCLUSIONS: The national incidence of NSI amongst Malaysian HCWs was lower compared with other countries, but unsafe practices remain an important concern. There is a need to formulate, implement and monitor safe and consistent practices for the different healthcare professionals.

Carbohydrate restriction for glycaemic control in Type 2 diabetes: a systematic review and meta-analysis.

AIM: To conduct a systematic review and meta-analysis to evaluate the effect of carbohydrate restriction on glycaemic control in Type 2 diabetes. METHODS: We searched Medline, EMBASE and CINAHL for the period between 1976 and April 2018. We included randomized controlled trials comparing carbohydrate restriction with a control diet which aimed to maintain or increase carbohydrate intake, and that reported HbA1c as an outcome and reported the amount of carbohydrate consumed during or at the end of the study, with outcomes reported at ≥3 months. RESULTS: We identified 1402 randomized controlled trials, 25 of which met the inclusion criteria, incorporating 2132 participants for the main outcome. Definitions of low carbohydrate varied among the studies. The pooled effect estimate from meta-analysis was a weighted mean difference of -0.09% [95% CI -0.27, 0.08 (P = 0.30); I2 72% (P <0.001)], suggesting no effect on HbA1c of restricting the quantity of carbohydrate. A subgroup analysis of diets containing 50-130 g carbohydrate resulted in a pooled effect estimate of -0.49% [95% CI -0.75, -0.23 (P <0.001); I2 0% (P = 0.56)], suggesting a clinically and statistically significant effect on HbA1c in favour of low-carbohydrate diets in studies of ≤6 months' duration. CONCLUSIONS: There was no overall pooled effect on HbA1c in favour of restricting carbohydrate; however, restriction of carbohydrate to 50-130 g per day had beneficial effects on HbA1c in trials up to 6 months. Future randomized controlled trials should be of >12 months' duration, assess pre-study carbohydrate intake, use recognized definitions of low-carbohydrate diets and examine reasons for non-adherence to prescribed diets in greater detail.

A regulatory approach on serum bilirubin level in subjects with impaired glucose tolerance.

The present study was undertaken to find the role of dietary intervention and physical exercise on serum bilirubin level in IGT subjects. Thirty three newly detected otherwise healthy subjects with IGT, aged 35-63 years, were randomly selected to participate in a 12 weeks diet and exercise program. Nine participants were within 35-40 years while majority fifteen participants aged 41-50 years and rest six participants were above 50 (51-63) years. A male preponderance was observed among the study participants where 53.3% of the total participants were male (n=16) and 46.7% were female (n=14). Mean bilirubin (mg/dl) level was recorded 0.68 ± 0.29 at base line and with follow-up, the value was 0.66 ± 0.26 mg/dl. For men (n=16), serum bilirubin were 0.77 ± 0.39 and 0.75 ± 0.36 mg/dl at base line and follow-up while for women (n=14), the values were 0.67 ± 0.33 and 0.59 ± 0.28 mg respectively. The 35-40 years group (n=9) showed bilirubin from 0.66 ± 0.23 at base line to 0.73 ± 0.19 mg/dl at follow-up while 41-50 years group (n=15) had 0.70 ± 0.34 and 0.58 ± 0.26 mg/dl and for 51-63 years group (n=6), the values were 0.65 ± 0.29 and 0.73 ± 0.33 mg/dl respectively. Participants with BMI 20-25 had bilirubin 0.62 ± 0.29 mg/dl at base line and 0.71 ± 0.21 mg/dl at follow-up while with BMI >25 (n=20) had 0.71 ± 0.30 and 0.63 ± 0.2 8 mg/dl respectively. No significant changes in serum bilirubin were observed among the groups and therefore, the dietary intervention and physical exercise during the period did not have a significant role in this respect.

Noninvasive carotid duplex study may be used as predictor test for ischaemic heart disease.

A prospective observational study was carried out to detect carotid atherosclerosis using high resolution B-Mode in 150 in-hospital patients with clinically diagnosed ischemic heart disease in various forms in the department of Cardiology, University Cardiac Center, BSMMU, Bangladesh. The duration of study was from April 2006 to December 2008. Carotid Ultrasound evaluation was performed in 150 patients diagnosed as Ischemic Heart Disease by single operator (NF). Mean age of the patients was 53.62±10.92 with, male to female ratio of 9.5:0.5. Mean IMT was 0.96±0.21mm in 85% of the patient of clinically diagnosed IHD, which was higher than the normal (normal IMT ≤0.8mm). Among them, about 77% had atherosclerotic plaque. A significant correlation between Carotid atherosclerosis determined by IMT and Ischemic Heart Disease (IHD) was found. Non invasive carotid duplex study might be useful for predicting ischaemic heart disease.

Anaemia and malnutrition in children aged 0-59 months on the Bijagós Archipelago, Guinea-Bissau, West Africa: a cross-sectional, population-based study.

BACKGROUND: Childhood malnutrition is the leading risk factor for the global burden of disease. Guinea-Bissau is a politically unstable country with high levels of childhood malnutrition and mortality. AIM: To determine the nutritional status of children on three remote islands of the Bijagós Archipelago, Bubaque, Rubane and Soga, and to identify factors associated with malnutrition and anaemia in this population in order to provide a baseline for future public health interventions. METHODS: A cross-sectional, population-based, door-to-door household survey of randomly selected households was undertaken to collect data on children aged 0-59 months (n = 872). Dietary information was collected using a validated questionnaire. Anthropometric measurements were collected using World Health Organization techniques. Capillary blood samples were analysed using a Hemocue®, with anaemia defined as Hb<11 g/dl. RESULTS: The prevalences of stunted, wasted and underweight children were 21.8%, 9.4% and 3.7%, respectively. These figures indicate moderate chronic malnutrition. The significant predictor variables for stunting were: age in months (OR 1.03), rural residence (OR 2.32), anaemia (OR 3.55) and residence on Soga island (OR 0.44). Stunting was more prevalent in males (25.4%) than in females (18.6%) (P = 0.03). The prevalence of anaemia was 80.2%. Age (OR 0.96), male gender (OR 1.81) and stunting (OR 2.87) were significant predictors. The Minimum Acceptable Diet was achieved by only 8.7% of children. CONCLUSION: The prevalence of malnutrition on the Bijagós Archipelago is less than half that on the mainland. This study is the first to determine the prevalence of anaemia in Guinea-Bissau, which, at 80.2%, is of severe public health concern. Future research should focus on the aetiology of stunting and anaemia, especially the contribution of infectious diseases and mother-child interaction. Iron supplementation should be strongly considered in this population.

Ramadan Prospective Diabetes Study: the role of drug dosage and timing alteration, active glucose monitoring and patient education.

AIMS: To observe the effects of active glucose monitoring, alteration of drug dosage and timing, dietary counselling and patient education in the occurrence of acute diabetic complications in fasting individuals with diabetes during the month of Ramadan. METHODS: This prospective study was conducted at the outpatient department of the Baqai Institute of Diabetology and Endocrinology. Two educational sessions, one about drug dosage and timing alteration and glucose monitoring, and the other about dietary and lifestyle modifications, were given to the patients by a doctor and a dietician, respectively. Patients who had been recruited were advised to note their blood glucose readings on a chart for at least 15 fasting days, twice a day with at least one reading in the fasting state. RESULTS: A total of 3946 readings were obtained in 110 subjects; 82 readings were in the hypoglycaemic range, and there were 22 episodes of symptomatic hypoglycaemia and 60 episodes of biochemical hypoglycaemia observed in 27 patients. Seven patients experienced symptomatic hypoglycaemia, whereas 20 patients had biochemical hypoglycaemia. Symptomatic hypoglycaemic episodes showed a downward trend from weeks 1 to 4. The highest frequencies of hypo- and hyperglycaemic episodes were observed pre-dawn. None of the patients developed diabetic ketoacidosis or hyperglycaemic hyperosmolar state. CONCLUSION: We observed that, with active glucose monitoring, alteration of drug dosage and timing, dietary counselling and patient education, the majority of the patients did not have any serious acute complications of diabetes during Ramadan.

Elevated serum homocysteine level has a positive correlation with serum cardiac troponin I in patients with acute myocardial infarction.

The objective of the present study is to find out whether the increased serum homocysteine level is associated with the increased serum troponin I as a surrogate marker of extent of myocardial injury in acute myocardial infarction patients. Elevated homocysteine levels are associated with increased thrombosis. In patients presenting with Acute Coronary Syndrome (ACS), it is not known whether this association is reflected in the degree of myocardial injury. This was a cross sectional study conducted among the patients with acute myocardial infarction in the Department of Cardiology, Dhaka Medical College Hospital during the period of October 2009 to September 2010 and which included 194 consecutive patients with acute myocardial infarction. The mean (+/- SD) serum homocysteine level was 20.2 +/- 14.3 micromol/L with range from 7.4 to 129.1 micromol/L. Mean serum troponin-I level was classified according to normal (<15 micromol/L) and high (> or = 15 micromol/L) levels of serum homocysteine values. The mean serum troponin-I level was 8.9 +/- 8.6 ng/ml in the patients having normal serum homocysteine level and 18.4 +/- 6.5 ng/ml in the patients having high serum homocysteine level. A significant positive correlation (r=0.273; p<0.001) was found between serum troponin-I level with homocysteine level. Patients with moderate hyperhomocysteinemia (> or = 15 micromol/L) was found to be 7.09 times more likely to have increased serum troponin-I (a surrogate marker of extent of myocardial injury). The main observation of the present study was that elevated serum homocysteine level has a positive correlation with serum cardiac troponin-I in patients with acute myocardial infarction. So serum homocysteine is associated with increased extent of myocardial injury as measured by serum cardiac troponin-I level, a surrogate marker in patients with acute myocardial infarction.

Lifestyle pattern in selected slums in Mymensingh Municipal area.

Lifestyle is composed of cultural and behavioural patterns and lifelong personal habits that developed through processes of socialization. Lifestyle may be health promotive or detrimental to health. Health requires the promotion of healthy lifestyle. Many current day health problems are associated with lifestyle changes. Because of rising urban population, the number of slum dwellers is rising. The mobility of people from rural to urban areas is the main reason of the growing slum population in cities. This Descriptive, cross-sectional study was directed to assess lifestyle pattern in four purposively selected slums in Mymensingh Municipal area. Non-Probability purposive type of sampling technique was used for selecting the study unit. Sample size was one hundred and twenty-three (123) families. Data were collected by interview with one of the adult family members, preferably with the head of the family, with mixed type of interviewer administered questionnaire. There were 494 family members with an average family size of 4.02, while mean age was 24.58 years with a standard deviation (SD) of 17.79 years. Male-female ratio was 103:100. Of 409 members over 5 years, 174(42.54%) did not have schooling and were illiterate. At least 105(33.02%) members were house-wives, and 99(81.15%) members were smokers. An overwhelming majority (79, 64.23%) families had monthly income between 2000 to 4999 taka. As many as 55(44.72%) families lived in kaccha house, while 40(32.52%) had to live in "Jhupree". In cent per cent families, tube well was the source of water for drinking and other household purposes. A highest majority 121(98.37%) of the families had latrine, while the remaining 2(1.63%) did not have any latrine, and defecate in open air. Of 121 families, 78(64.46%) families had sanitary latrine, while 43(37.54%) did not have sanitary latrine. It was revealed that 86(69.92%) families had cell-phone, while 65(52.85%) families had television, 10(8.13%) families had radio, and 5(4.06%) families had DVD/VCR for recreational facilities. As many as 75(60.98%) respondents had correct knowledge, while the rest 48(39.02%) had incorrect knowledge on hand washing. Of 75, at least 66(88.00%) respondents practiced hand washing, while 9(12.00%) respondents did not practice it. As many as 110(89.43%) members sought medical help for major and minor illness of their family members, whereas the rest 13(10.57%) families did not. Of 110, 62(56.36%) families paid visit to government Hospital, while 22(20.00%) visited to private clinic, 12(10.90%) to pharmacy, 10(9.10%) to qualified doctors and 4(3.64%) to the traditional healers. As many as 58(52.71%) respondents mentioned that they preferred as the facilities cater service free of cost, while 32(29.10%) preferred for better and effective treatment, 16(14.55%) for close to their residence and 4(7.27%) for their belief. Living condition of slum dwellers is considerably low due to low income and inadequate education. Moreover, poor physical environment with unsanitary excreta disposal method is commonplace in slum areas. Existing lifestyle of slum dwellers is unacceptable, and should be improved so that they can contribute to the national development.

Self-Monitoring of Blood Pressure in Hypertension: A UK Primary Care Survey.

This study aimed to determine the prevalence of Self-Monitoring Blood Pressure amongst people with hypertension using a cross-sectional survey. Of the 955 who replied (53%), 293 (31%) reported that they self-monitored blood pressure. Nearly 60% (198/331) self-monitored at least monthly. Diabetic patients monitoring their blood glucose were five times more likely than those not monitoring to monitor their blood pressure. Self-monitoring is less common in the UK than internationally, but is practiced by enough people to warrant greater integration into clinical practice.

A randomized controlled trial of the effect of thyroxine replacement on cognitive function in community-living elderly subjects with subclinical hypothyroidism: the Birmingham Elderly Thyroid study.

CONTEXT: Subclinical hypothyroidism (SCH) and cognitive dysfunction are both common in the elderly and have been linked. It is important to determine whether T4 replacement therapy in SCH confers cognitive benefit. OBJECTIVE: Our objective was to determine whether administration of T4 replacement to achieve biochemical euthyroidism in subjects with SCH improves cognitive function. DESIGN AND SETTING: We conducted a double-blind placebo-controlled randomized controlled trial in the context of United Kingdom primary care. PATIENTS: Ninety-four subjects aged 65 yr and over (57 females, 37 males) with SCH were recruited from a population of 147 identified by screening. INTERVENTION: T4 or placebo was given at an initial dosage of one tablet of either placebo or 25 microg T4 per day for 12 months. Thyroid function tests were performed at 8-weekly intervals with dosage adjusted in one-tablet increments to achieve TSH within the reference range for subjects in treatment arm. Fifty-two subjects received T4 (31 females, 21 males; mean age 73.5 yr, range 65-94 yr); 42 subjects received placebo (26 females, 16 males; mean age 74.2 yr, 66-84 yr). MAIN OUTCOME MEASURES: Mini-Mental State Examination, Middlesex Elderly Assessment of Mental State (covering orientation, learning, memory, numeracy, perception, attention, and language skills), and Trail-Making A and B were administered. RESULTS: Eighty-two percent and 84% in the T4 group achieved euthyroidism at 6- and 12-month intervals, respectively. Cognitive function scores at baseline and 6 and 12 months were as follows: Mini-Mental State Examination T4 group, 28.26, 28.9, and 28.28, and placebo group, 28.17, 27.82, and 28.25 [not significant (NS)]; Middlesex Elderly Assessment of Mental State T4 group, 11.72, 11.67, and 11.78, and placebo group, 11.21, 11.47, and 11.44 (NS); Trail-Making A T4 group, 45.72, 47.65, and 44.52, and placebo group, 50.29, 49.00, and 46.97 (NS); and Trail-Making B T4 group, 110.57, 106.61, and 96.67, and placebo group, 131.46, 119.13, and 108.38 (NS). Linear mixed-model analysis demonstrated no significant changes in any of the measures of cognitive function over time and no between-group difference in cognitive scores at 6 and 12 months. CONCLUSIONS: This RCT provides no evidence for treating elderly subjects with SCH with T4 replacement therapy to improve cognitive function.

Cutis laxa: a case report and an update.

Very few cases of Cutis Laxa are reported worldwide. This is the first case report of its kind from Bangladesh. A 10 year-old girl looking very aged was admitted in the paediatric ward of Dhaka Medical College with most striking skin feature. There was loosely hanging skin over the face which was inelastic, hyper extensible and which recoils slowly after stretching. She had downward slanting palpebral fissures, periorbital oedema, a broad flat nose with everted nostril, sagging cheeks, and large and soft ears. Skin biopsy showed fragmentation of the elastic tissue with collagen tissue in the dermis, which was suggestive of Cutis Laxa. Her chest x-ray showed hypertranslucent lung fields, prominence of pulmonary conus area and some ring like opacity near the lower zone with cardiomegaly, which is suggestive of corpulmonale with bronchiectasis. Her echocardiography showed dilated right atrium, ventricle and pulmonary artery which were suggestive of corpulmonale. All these confirmed the diagnosis.

The use of clinical photography by UK general dental practitioners.

AIM: The aim of this study was to assess by means of a postal questionnaire the numbers of general dental practitioners (GDPs) who used clinical photography and for what application. METHOD: The questionnaire was distributed to 1,000 randomly selected dentists in the UK with an explanatory letter and reply paid envelope. The data collected was computerised and analysed statistically. RESULTS: Five hundred and sixty-two replies were received. Of the respondents, 48% used clinical photography, with 59% using a digital camera, 34% a 35 mm camera and 19% a video camera. Principal uses of clinical photography were treatment planning (84%), patient instruction/motivation (75%), medico-legal reasons (71%) and communication with the laboratory (64%). CONCLUSION: Clinical photography was used by 48% of general dental practitioner respondents.

Increased serum ferritin levels in amyotrophic lateral sclerosis (ALS) patients.

Iron misregulation promotes oxidative stress, a proposed pathological mechanism in neurodegenerative disease. The aim of this study was to evaluate serum iron metabolism indicators in 60 amyotrophic lateral sclerosis (ALS) patients and 44 age matched controls. Serum ferritin levels were significantly increased in ALS patients compared to controls (p < 0.001), while no differences in the levels of serum iron, transferrin, iron saturation or total iron binding capacity were found. Likewise no differences in C reactive protein (CRP) or caeruloplasmin were detected, suggesting that the elevated ferritin levels in ALS did not merely indicate an acute phase response. The increased ferritin level may reflect a general increase in stored iron or be a consequence of ongoing muscle degeneration.

Total serum cholesterol levels and Alzheimer's dementia in patients with Down syndrome.

BACKGROUND: The risk for dementia in Alzheimer's disease (DAD) in adults with Down syndrome (DS) is higher than in the general adult population. Hypercholesterolaemia has been reported as a risk factor for DAD in the general population. This study investigated the role of serum cholesterol levels in the onset of DAD in the DS population. METHODS: This study investigated total serum cholesterol levels in 179 DS persons (with and without DAD). The possible association between Apolipoprotein E and amyloid beta1-40 and beta1-42 levels was also investigated. RESULTS: No statistically significant association was found between total serum cholesterol levels and dementia in AD or with amyloid beta levels. However for DS adults with an apoE epsilon4 allele significantly higher serum cholesterol levels were found. CONCLUSION: Hypercholesterolaemia is not a risk factor for DAD in persons with DS. However, DS persons with an apoE epsilon4 allele are susceptible to high serum cholesterol. Such individuals should be screened on a regular basis.

On-chip deposition of carbon nanotubes using CMOS microhotplates.

The direct deposition of carbon nanotubes on CMOS microhotplates is demonstrated in this paper. Tungsten microhotplates, fabricated on thin SOI membranes aside CMOS control circuitry, are used to locally grow carbon nanotubes by chemical vapour deposition. Unlike bulk heating of the entire chip, which could cause degradation to CMOS devices and interconnects due to high growth temperatures in excess of 500 °C, this novel technique allows carbon nanotubes to be grown on-chip in localized regions. The microfabricated heaters are thermally isolated from the rest of the CMOS chip as they are on the membranes. This allows carbon nanotubes to be grown alongside CMOS circuitry on the same wafer without any external heating, thus enabling new applications (e.g. smart gas sensing) where the integration of CMOS and carbon nanotubes is required.

Mentally disordered offenders in Zimbabwe and in England and Wales: a socio-demographic study.

Our aim was to compare socio-demographic, clinical and criminal characteristics of mentally disordered offender patients in a special institution in a developing and a developed country. Zimbabwe data from 1980-1990 was obtained from a hospital patient survey, in a written semistructured format. The English special (high security) hospital patients' data for the same period was obtained from the case register. The sample size for Zimbabwe was 367 patients (337 males, 30 females) and for England and Wales it was 1,966 patients (1,643 males, 323 females). The average age for Zimbabwean patients was 36 years, with standard deviation of 9.7; for England and Wales the average age was 29.7 with standard deviation of 9.6. There was significant difference in marital status in the two countries. Seventy-eight per cent of patients were single in England and Wales, compared with 49% in Zimbabwe. There were 20% illiterate patients in Zimbabwe, compared with 4% in England and Wales. Thirty-seven per cent of the patients in England and Wales had a diagnosis of personality disorder, compared with 6% in Zimbabwe. There were 53% of homicides in Zimbabwe, compared with 20% in England and Wales. Employment in the two countries was similar: 34% in Zimbabwe and 33% in England and Wales. There were differences in the socio-demographic characteristics in the two countries, except for employment status. Differences were also noticed in the diagnoses of the patients, types of crime and the methods of assault.