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By: Leonard S. Lilly, MD

  • Professor of Medicine, Harvard Medical School, Chief, Brigham and Women's/Faulkner Cardiology, Brigham and Women's Hospital, Boston, Massachusetts

https://connects.catalyst.harvard.edu/Profiles/display/Person/26967

The original and subsequent studies have analyzed serial murders from a number of perspectives medicines discount kytril 2mg line, including historical reviews medications not to take with grapefruit cheap kytril 1 mg overnight delivery, individual case studies medicine 666 effective 2 mg kytril, descriptive projects medications 3 times a day kytril 2 mg, and causality factors. While developmental information concerning a serial killer provides interesting insights, it has little utility in helping identify an unknown offender during an active serial murder investigation for a number of reasons. First, this developmental information provides minimal assistance in highlighting potential suspects. Since individuals who are suspected of committing a crime do not usually divulge sensitive information concerning their childhood, especially regarding physical, emotional, or sexual abuse, these factors can remain hidden from an active law enforcement investigation. Second, there are significant legal restraints involved in gathering certain background information during an investigation, particularly those records that are safeguarded under privacy issues, such as medical and psychological records. Third, it would be extremely time and manpower intensive for law enforcement personnel to obtain this information. Routinely, this information is gathered by conducting interviews of family members and acquaintances of the potential offender. This effort would be compounded in order to obtain the same information from multiple potential suspects. Fourth, even if investigators were able to acquire these records, the information would be of limited value. This is due to the wide range of factors involved in the upbringing and development of serial killers. All of these factors highlight the need for updated research material viewed through an investigative prism that is based upon information that would be available to law enforcement investigators working an active unsolved serial murder case. For the past five years, this project gathered information from solved case files to construct a database containing serial murder cases, the offenders who commit them, and their unfortunate victims. This viewpoint will ultimately allow investigators to identify a number of situational factors based upon the particular body disposal scenario. Some of these factors include the approach an offender used to gain access to a given victim, the motivation involved in the crime, and the nature of the relationship between the offender and the victim. The goal in publishing this monograph is to provide law enforcement investigators with relevant data that assists in the identification, arrest and conviction of serial murder offenders. Additionally, the research data that is provided will offer a wide variety of pertinent information on serial murder in general. Included in this monograph are descriptive statistics and other measures that were utilized to gain a better understanding of the different types of offenders in this study. Lastly, this monograph will provide mental health practitioners, academicians, and law enforcement professionals with data that adds to the over-all body of knowledge concerning serial murder. The goal of this analysis process is to provide law enforcement agencies with a better understanding of the motivations and behaviors of offenders. The analysis is a tool that provides investigators with descriptive and behavioral characteristics of the most probable offender and advice regarding investigative techniques to help identify the offender. There are sections that provide law enforcement with an overview of serial murder investigations, as well as sections that address the implications of the various body disposal scenarios used by serial killers and discusses how this information can be used to highlight certain offender characteristics. The study parameters and results section contains the statistical data of the study. The data was substantial enough to allow the authors to search frequencies and common occurrences between the body disposal scenario, other behaviors at the crime scene, the criminal history of the offender, and the relationship between the offender and the victim. Included within these sections are comparisons between individual offenders based upon how many victims were killed by each serial killer. Additionally, a number of specific categories were isolated from the larger data set to provide information to law enforcement on these unique sets of serial murder. This monograph is not intended to provide a "profile" of serial murder offenders who fall into each pathway. However, this monograph is intended to provide guidance, insight, and knowledge concerning the behaviors and activities of these types of offenders. These cases involve multiple victims; the series may span days, months or even years; they can involve several jurisdictions; the motive involved may not be easily discerned; offender behaviors may not be consistent among all the cases; and there may be no obvious relationship between the offenders and the victims. Serial murder cases are also very rare and most law enforcement investigators do not have the same level of experience in investigating serial murder as they do with other types of crimes.

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See Diabetic retinopathy Retracting apical impulse medicine z pack discount kytril 1 mg on line, 314­316 Retracting systolic movement medicine recall order 1 mg kytril free shipping, 312 Retroclavicular goiter medications errors buy kytril 2 mg online, 195 Reversed pulsus paradoxus symptoms 5 weeks pregnant cramps effective kytril 2mg, 104 Revised Geneva score, 283, 284t, 285b­286b Rhonchi, 31t­36t, 260, 260t Rhythm. See also Pulse rhythm, abnormalities of bigeminal, 111 quadruple, 337, 341 train wheel, 337 trigeminal, 110, 112 of ventricular pulse, 118, 118f Right base, 310 Right ventricular movements, 317 Right-to-left shunting of blood through intrapulmonary shunts, 155 through patent foramen ovale, 155 Rigidity, 442, 555­557 of muscles, 31t­36t, 55­57, 553 Rinne test, 187, 188f, 189, 190t Risk for coronary artery disease, 420­421 of mitral valve prolapse, 394 of obesity, 82 Romberg sign, 57­59 Rotator cuff tears of, 488­490 palpation of, 485, 487f tendinitis of, 487­488 Rovsing sign, 443 Rumpel-Leede test, 31t­36t, 133­134 S1. See also Abnormal splitting, of S2; Second heart sound prominent, of S1, 329 Spurling test, 31t­36t, 597 Stance and gait, 31t­36t, 48­62 canes for, 62 evaluation of, 60­62 gait disorders etiology of, 48 significance of, 48­59 types of, 48­59 introduction to, 48 Static technique, 515 -Statistic, 29­30, 31t­37t, 36­39 calculation for, 36­39, 38f Stenosis. See also Aortic stenosis mitral, 327, 387 Sternal angle, 294­295 Stethoscope, 320­321 for heart auscultation, 320­321 pressure with, 124 for third and fourth heart sounds, 337­338 Stocking-glove sensory loss, 578 Strength, of muscles, 31t­36t, 550­551 Stridor, 260, 266 Stroke, 48, 173. See also Regular tachycardia paroxysmal, 99 types of, 114 ventricular, 116b Tachypnea, 31t­36t, 136, 146, 147b and oxygen saturation, 146 Tactile fremitus, 31t­36t, 239­240, 241b­242b asymmetrical, 240 findings of, 239­240 technique for, 239­240 Tactile recognition, 571 Tactile stimulation, bilateral simultaneous, 571 Tandem gait testing, 621 Task-related tremors, 619 Taylor hammer, 581 Technologic test, 4f, 5 Technology, in modern medicine, 3 Temperature, 135­144 axillary, 136 clinical significance of, 139­144 findings of, 137­139 anhidrosis, 139 fever patterns, 137f, 137­138 focal, 138 muscle rigidity, 139 relative bradycardia, 138­139 introduction to, 135 normal, 135, 136f fever and, 137, 137f oral, 135­136 in simple sensations, 568­569 technique for, 135­136 Temperature measurement site of, 135­136 tympanic, 135­136 variables of, 135­136 cerumen, 136 eating and smoking, 135­136 hemiparesis, 136 tachypnea, 136 Tenderness. See also Adie tonic pupil clinical significance of, 174 findings of, 174 pathogenesis of, 174 Topical anticholinergic drug, 174­176 Topographic percussion, 243, 246­248, 249b­250b Train wheel rhythm, 337 Traube space dullness, 435 Trauma to head, 171 to iris, 168 Tremors, 619­620 Trendelenburg gait, 50f, 51­53 clinical significance of, 53 definition of, 51 etiology of, 51 Trendelenburg sign, 53 Trepopnea, 153­155 clinical significance of, 154 findings of, 154 Tricuspid regurgitation, 306, 316. See Acute vertigo, imbalance and Vesicular breath sounds, 251­253, 252f Vestibulo-ocular reflex, 629­630, 630f Visceral fat, obesity and, 83­84 Visual acuity, diabetic retinopathy and, 183 Visual field defects, 513, 517b­518b anterior, 516 chiasmal, 516 detection of, 518­520 etiology of, 516 postchiasmal, 516­518 prechiasmal, 516 Visual field testing, 513­520 clinical significance of, 516­520 definition of, 513 diagnostic accuracy of, 516­517 findings of, 515­516 introduction to, 513 technique for, 515, 519b kinetic, 515 static, 515 visual pathways anatomy in, 513­515, 514f Visual pathways anatomy, 513­515, 514f Vital signs, 131­132, 132t postural, 122, 131 Vocal fremitus. See also Venous waveforms cannon A, 114, 306 flutter, 115 Wayne index, 207, 208b, 209, 209t Weak quadriceps gait, 54 Weakness. See Waist-to-hip ratio Wide and fixed splitting, 333­334 Wide fixed splitting, 331 Wide physiologic splitting, 331, 333 Wounds, nonhealing predictors of, 469 Wrong-way tongue deviation, 637 Wunderlich curves, 135, 137 W X and Y descents, 304 X Yergason sign, 482, 484f Y this page intentionally left blank. Some of the impacted facilities, such as those shelters, kennels, groomers and daycares, were forced to close for weeks. And, better understanding of infectious diseases and preventative care, including strategic vaccination and cleaning protocols, can help keep pets healthy. I am very proud to be part of the Infectious Disease Handbook, which was created to help both veterinary and pet businesses create facilities dedicated to being disease free, ultimately bettering pets, and saving dog caretakers money and saving them from heartache. There is too much misinformation, distortion, or half-truths found online; I want to emphasize that the information in this handbook is written by real experts and includes the most up-to-date information available. One single gram of feces can contain up to 10 million infective doses of parvovirus. Both protocols can be successful, with a survival only slightly lower in outpatients. Treatment Treatment of the canine parvovirus patient is aimed towards fluid therapy, antibiotic therapy, nutritional support, gastrointestinal support, supportive care, and monitoring. Effects of canine parvovirus strain variations on diagnostic test results and clinical management of enteritis in dogs. While this disease is rarely seen now due to vaccination, it is more prevalent in areas where there is an increased prevalence of unvaccinated animals. Signs of Disease Clinical signs of distemper include: Anorexia Lethargy/Listlessness Malaise Fever Purulent nasal discharge Conjunctivitis Purulent ocular discharge Upper respiratory infection Cough Dyspnea Skin pustules Vomiting Diarrhea Ataxia Tremors Chewing-gum fits Seizures Myoclonus Hypersalivation Hyperkeratosis of the paw pads Paralysis Death Acute signs can be seen in as little as 1-2 weeks, but these can progress to delayed neurologic signs within weeks to months. In patients with viral pneumonia or secondary bacterial pneumonia, broad spectrum antibiotic therapy is warranted. Patients should be carefully monitored for signs of dyspnea or hypoxemia; humidified oxygen therapy is indicated for patients with a pulse oximeter reading < 93%. Finally, nursing care such as wiping away nasal and ocular discharge, keeping patients warm and dry, and monitoring is indicated. Transmission/Incubation Oronasal exposure is the most common route of infection resulting from ingestion of urine, feces, or saliva of infected dogs. Chronic hepatitis in dogs: A review of current understanding of the etiology, progression, and treatment. Rabies, a lyssavirus in the Rhabdovirus family, is a preventable viral disease of mammals. While there are expected time frames where each phase will present, phases may be variable and overlap: Prodromal phase: Signs in the stage may be vague including behavioral changes, mydriasis (dilated pupils), hyperesthesia, and fever. Foaming at the mouth from an inability to swallow food or water due to an absent swallowing reflex may also be seen. Other classifications include the furious form of rabies or the dumb/paralytic form of rabies. The term "furious rabies" refers to animals in which aggression (the excitative phase) is pronounced. Even more concerning, dogs, cats, and ferrets may shed virus for several days before onset of clinical signs. Most rabies cases in dogs show clinical signs within 21­80 days following exposure, but the incubation period may be shorter or considerably longer ranging from 3 weeks to over 6 months depending on the site of infection, the amount of virus deposited, and the species involved. Areas where rabies is uncommon may not have this on the expected differential list, making evaluation even more challenging.

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These measures also have the beneft of providing targets for intervention treatment neuroleptic malignant syndrome buy kytril 1 mg, given the changeable nature of dynamic risk factors symptoms uterine cancer discount kytril 1mg without a prescription. Introduction A lthough the desire to symptoms wheat allergy discount kytril 1mg predict the risk of future violence posed by individuals is likely centuries old medicine 44291 buy discount kytril 1 mg, risk assessment efforts until recently have been relatively unsuccessful in terms of their predictive accuracy. Notwithstanding pseudoscientifc methods such as phrenology (which claimed to gauge behavior propensities based on measurements of the skull), risk assessment for many decades has primarily involved individual mental health professionals applying their accumulated experience and clinical acumen to produce a clinical judgment of the degree of risk posed by a particular individual. The ability to accurately assess the likelihood of future violent acts - and future criminal behavior more generally - is important to clinicians, policymakers and the public alike. In this context, risk assessment typically involves arriving at an estimate of the likelihood that an offender will recidivate (that is, revert to illegal behavior) after the individual experiences legal consequences or intervention for a prior criminal act. It is often undertaken for dispositional purposes to help determine, for example, an appropriate sentence or custody level or the conditions of community supervision. In these situations, decisions are often predicated, at least in part, on the assessed likelihood of recidivism, with resources being allocated accordingly to promote community safety (Kingston et al. Indeed, estimates of risk for sex offenders are used in various community corrections, institutional corrections and civil commitment decisionmaking contexts. Thus, the scientifc and theoretical underpinnings of risk assessment are a critical component of the successful management of adult sexual offenders (Hanson & Bourgon, in press; Mann, Hanson & Thortnon, 2010; Tabachnick & Klein, 2011). Arguing from a policy standpoint, Tabachnick and Klein (2011) have stated that the results of actuarial risk assessments in particular should inform decision-making at all levels regarding the supervision of adult sexual offenders in order to prevent recidivism. Given the role played by risk assessment in high-stakes decisions such as those involving potential civil commitment for those designated as sexually violent predators, as well as the possibility of lifetime community supervision, reliance on methods and procedures possessing a strong scientifc evidence base is especially critical. While much progress has been made regarding the ability of professionals in the feld to accurately estimate the likelihood of future sexual reoffense, no one is presently able to estimate either the timing or the severity of such future criminal conduct (J. Therefore, it is critically important to establish a clear understanding of exactly what risk is being assessed and to frame expectations accordingly. Current methods at present allow, in most cases, only for an estimate of the likelihood of both future sexual and nonsexual offending over a specifc timeframe. The accuracy of these estimates depends in part on the degree to which the individual offender being assessed matches a known group of sex offenders (knows as the normative sample or norm group) and the degree to which the factors included in the risk assessment accurately refect the known universe of relevant risk factors. Review of Research Sex offender risk assessments are most often employed in applied forensic settings for purposes of decisionmaking (Doren, 2002). The typical venues for sex offender risk assessment include - Sentencing and criminal adjudications, during which the results of the assessment are used to ascertain appropriate levels and periods of confnement and/or community supervision. Sex Offender Management Practices Across the Criminal Justice Spectrum Case Processing Arrest and Investigation Prosecution and Defense Sentencing and Disposition Corrections Corrections Programming Treatment Re-entry and Tracking Supervision Treatment Registration Community Notifcation Community Support Prevention and Education Victim Services and Outreach Community Involvement Methods of assessing sex offender risk can generally be categorized as follows (Hanson, 1998): Unguided (or unstructured) clinical judgment: the evaluator1 reviews case material and applies personal experience to arrive at a risk estimate, without relying on a specifc list of risk factors or underlying theory to prioritize or weight any of the information used. The instrument is used to identify the presence or absence of each risk factor, and an estimate of risk is arrived at through a standard, prescribed means of combining the factors. This approach is the only risk assessment method that can be scored using a computerized algorithm or by minimally trained nonclinicians. Comparisons of the above-described approaches to risk assessment have a long, and at times contentious, history (Grove, 2005; Grove & Meehl, 1996; Grove et al. Phenix, personal communication, May 10, 2011), each of the structured approaches has its merits as well as its supporters and detractors (Doren, 2002; A. Nonetheless, recent research (Hanson & Morton-Bourgon, 2009) suggests that pure actuarial assessments should be favored over other approaches (Hanson, 2009). As regards the adjusted actuarial approach, a number of recent studies (Hanson, Helmus & Harris, 2015; Storey, Watt, Jackson & Hart, 2012; Wormith, Hogg & Guzzo, 2012) have demonstrated that clinical adjustment of actuarial results more often than not decreases the accuracy of the actuarial measure, and thus, this practice is not recommended. By including dynamic risk factors in the assessment process, third-generation risk assessments can be used to both guide and evaluate the impact of intervention efforts. Current developments in the feld confrm the promise of third-generation risk assessment methods, as research tells us more about the relationship between specifc dynamic factors and risk for recidivism (Hanson, 2011; Mann, Hanson & Thornton, 2010; A. Recent studies have in fact demonstrated that the inclusion of dynamic risk factors can contribute incrementally to the ability of static (relatively unchangeable) risk factors to accurately predict risk for sexual reoffense (Eher et al. There are three generations of risk assessment methods: unstructured professional opinion, actuarial methods using static predictors and methods that include both static and dynamic factors. For accurate risk assessment to occur, the factors associated with the type of risk being assessed must be known. Knowledge about the risk factors associated with recidivism typically is generated through research in which the recidivism rate for offenders with a particular characteristic is compared to the recidivism rate for offenders without that characteristic, or for offenders possessing other characteristics (Hanson, 2000). To date, no single characteristic (that is, "risk factor") has been found in isolation to be a robust predictor of recidivism.

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The risk-need-responsivity model emerged from more than 30 years of research on interventions for criminal offenders 97110 treatment code buy 1 mg kytril visa. This research has produced a body of evidence that clearly demonstrates that rehabilitation works (Gendreau & Ross symptoms hyperthyroidism purchase kytril 2 mg free shipping, 1987; Lipsey & Cullen medicine quizlet order kytril 2mg amex, 2007; Joliffe & Farrington medications in checked baggage buy cheap kytril 1 mg line, 2007). It also has demonstrated that effective interventions share a common set of features. These common characteristics form what criminologists Don Andrews, Paul Gendreau and their colleagues have called the "principles of effective intervention" (Andrews, 1995; Gendreau, 1996; Gendreau, Goggin & Smith, 1999; Andrews & Dowden, 2005). Higher-risk offenders are more likely to beneft from treatment than lower-risk offenders. In practice, more intensive levels of treatment should be reserved for higher-risk offenders. In fact, using high levels of treatment with low-risk offenders is not only ineffcient, it can actually increase recidivism (Lovins, Lowenkamp & Latessa, 2009; Wilson, 2007). To effectively reduce recidivism, programs should target the criminogenic needs of higher-risk offenders. Criminogenic needs are dynamic risk factors that are related to subsequent offending, such as substance abuse or an antisocial lifestyle. Dynamic risk factors can be changed through programming, whereas static risk factors, such as criminal history and age at frst arrest, cannot. Successful programs are responsive to the motivation, cognitive ability and other characteristics of the offender. In essence, therapeutic interventions must be tailored to the learning style and capabilities of the offender. Research has demonstrated that programs incorporating the risk-need-responsivity model are far more effective at reducing recidivism than those that do not (Andrews & Bonta, 2006). Given the strong scientifc evidence supporting the effcacy of treatment for offenders overall, and the role that risk-need-responsivity plays in effective treatment, there is a growing interest in applying the risk-need-responsivity model to treatment for sex offenders. Using the Guidelines of the Collaborative Outcome Data Committee, which were explicitly developed to assess the quality of research on sex offender treatment outcomes, the researchers excluded from the analysis more than 100 potentially relevant studies because they did not meet minimum levels of study quality. However, of the 23 studies that were fnally included in the analysis, only fve (22 percent) were rated as good in terms of methodological quality; 18 were rated as weak. The researchers also found that adhering to the risk-need-responsivity model increased treatment effectiveness. While treatment that adhered to one or two of the principles was more effective than treatment that did not adhere to any of the principles, treatment that adhered to all three principles was most effective. A study by Lovins, Lowenkamp and Latessa (2009) examined the direct effects of the risk principle on sex offenders. The researchers sought to determine whether intensive treatment was more effective for higherrisk sex offenders and whether less-intensive treatment had greater effects for lower-risk sex offenders. The study sample included 348 sex offenders paroled from a state correctional institution. Of this sample, 110 were released to a halfway house for residential sex offender treatment and 238 were released directly to the community. While offenders released directly to the community may have received outpatient treatment, sex offenders released to a halfway house were subjected to a more intensive level of treatment. The researchers examined general recidivism but not sexual recidivism in the study. Results showed that intensive treatment was effective in reducing recidivism for all risk categories of offenders, except low-risk offenders. In fact, high-risk offenders who completed intensive residential treatment were more than two times less likely to recidivate than high-risk sex offenders who did not receive intensive treatment. Conversely, low-risk sex offenders who received intensive treatment were 21 percent more likely to recidivate than low-risk sex offenders who were released directly to the community. These fndings lend further support to the importance of the principles of effective intervention in sex offender treatment programming.

References:

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  • http://nchpakistan.gov.pk/images/UploadImages/BHMS-Syllabusc8f.pdf
  • https://www.aafp.org/afp/2008/1001/afp20081001p853.pdf
  • https://saragottfriedmd.com/dev/wp-content/uploads/2014/04/TTHC-W1-FAQs-Curriculum.pdf
  • https://pmj.bmj.com/content/postgradmedj/33/381/327.full.pdf