By F. Mezir. Troy State University - Dothan. 2019.
The normal “doctor–patient” relationship does not apply; the forensic physi- cian–detained person relationship requires that the latter understands the role of the former and that the former takes time to explain it to the latter cheap 10 mg prednisolone visa. Meticulous attention to detail and a careful documentation of facts are required at all times generic prednisolone 20 mg visa. You will never know when a major trial will turn on a small detail that you once recorded (or prednisolone 10mg visa, regrettably, failed to record). Your work will have a real and immediate effect on the liberty of the individual and may be highly influential in assisting the prosecuting authorities to decide whether to charge the detained person with a criminal offense. You may be the only person who can retrieve a medical emergency in the cells—picking up a subdural hematoma, diabetic ketoacidosis, or coro- nary thrombosis that the detaining authority has misinterpreted as drunken- ness, indigestion, or simply “obstructive behavior. Get it wrong, and you may not only fail to prevent an avoidable death but also may lay yourself open to criminal, civil, and disciplinary proceedings. You clearly owe a duty of care to those who engage your services, for that is well-established law. The issue of whether a forensic physician owes a wider duty to the victims of alleged crime was decided in the English Court of Appeal during 1999 (35). On December 20, the judge accepted a defense submission of no case to answer and directed the jury to return a verdict of not guilty. She claimed to suffer persistent stress and other psychological sequelae from fail- ing to secure the conviction of her alleged assailant and knowing that he is still at large in the vicinity. The claimant did not contend that there was any general duty of care on the part of a witness actionable in damages at the suit of another witness who may suffer loss and damage through the failure of the first witness to attend and give evidence in accordance with his or her witness statement. When the case came before the Court of Appeal, Lord Justice Stuart- Smith stated that the attempt to formulate a duty of care as pleaded, “is wholly misconceived. If a duty of care exists at all, it is a duty to prevent the plaintiff from suffering injury, loss or damage of the type in question, in this case psychiatric injury. A failure to attend to give evidence could be a breach of such duty, but it is not the duty itself. It seems to me that she must have owed a duty of care to carry out any examination with reasonable care, and thus, for example, not to make matters worse by causing injury to the plaintiff. Revised interim guidelines on confidentiality for police surgeons in England, Wales and Northern Ireland. Association of Police Surgeons (now the Association of Forensic Physi- cians), East Kilbride. The Stationery Office, London, 1999; and on the Department of Constitutional Affairs (formerly Lord Chancellor’s Department). Sexual Assualt Examination 61 Chapter 3 Sexual Assault Examination Deborah Rogers and Mary Newton 1. All health professionals who have the potential to encounter victims of sexual assaults should have some understanding of the acute and chronic health problems that may ensue from an assault. However, the pri- mary clinical forensic assessment of complainants and suspects of sexual assault should only be conducted by doctors and nurses who have acquired specialist knowledge, skills, and attitudes during theoretical and practical training. There are many types of sexual assault, only some of which involve pen- etration of a body cavity. This chapter encourages the practitioner to under- take an evidence-based forensic medical examination and to consider the nature of the allegation, persistence data, and any available intelligence. The chapter commences by addressing the basic principles of the medical examination for both complainants and suspects of sexual assault. Although the first concern of the forensic practitioner is always the medical care of the patient, thereafter the retrieval and preservation of forensic evidence is para- mount because this material may be critical for the elimination of a suspect, identification of the assailant, and the prosecution of the case. Thus, it is imper- ative that all forensic practitioners understand the basic principles of the foren- sic analysis. Thereafter, the text is divided into sections covering the relevant body areas and fluids. Each body cavity section commences with information regard- From: Clinical Forensic Medicine: A Physician’s Guide, 2nd Edition Edited by: M. This specialist knowledge is manda- tory for the reliable documentation and interpretation of any medical findings. The practical aspects—which samples to obtain, how to obtain them, and the clinical details required by the forensic scientist—are then addressed, because this takes priority over the clinical forensic assessment. The medical findings in cases of sexual assault should always be addressed in the context of the injuries and other medical problems associated with con- sensual sexual practices. Therefore, each section summarizes the information that is available in the literature regarding the noninfectious medical compli- cations of consensual sexual practices and possible nonsexual explanations for the findings. The type, site, and frequency of the injuries described in asso- ciation with sexual assaults that relate to each body area are then discussed. Unfortunately, space does not allow for a critical appraisal of all the chronic medical findings purported to be associated with child sexual abuse, and the reader should refer to more substantive texts and review papers for this infor- mation (1–3). Throughout all the stages of the clinical forensic assessment, the forensic practitioner must avoid partisanship while remaining sensitive to the immense psychological and physical trauma that a complainant may have incurred. Although presented at the end of the chapter, the continuing care of the com- plainant is essentially an ongoing process throughout and beyond the primary clinical forensic assessment. Immediate Care The first health care professional to encounter the patient must give urgent attention to any immediate medical needs that are apparent, e. Nonetheless, it may be possible to have a health care worker retain any clothing or sanitary wear that is removed from a complainant until this can be handed to someone with specialist knowledge of forensic packag- ing. Timing of the Examination Although in general terms the clinical forensic assessment should occur as soon as possible, reference to the persistence data given under the relevant sections will help the forensic practitioner determine whether the examination of a complainant should be conducted during out-of-office hours or deferred Sexual Assualt Examination 63 until the next day. Even when the nature of the assault suggests there is unlikely to be any forensic evidence, the timing of the examination should be influenced by the speed with which clinical signs, such as reddening, will fade. Place of the Examination Specially designed facilities used exclusively for the examination of com- plainants of sexual offenses are available in many countries. The complainant may wish to have a friend or relative present for all or part of the examination, and this wish should be accommodated. Suspects are usually examined in the medical room of the police station and may wish to have a legal representative present. During the examinations of both complainants and suspects, the local ethical guidance regarding the conduct of intimate examinations should be followed (4). Consent Informed consent must be sought for each stage of the clinical forensic assessment, including the use of any specialist techniques or equipment (e. When obtaining this consent, the patient and/or parent should be advised that the practitioner is unable to guarantee confidentiality of the material gleaned during the medical examination because a judge or other presiding court officer can rule that the practitioner should breach medical confidentiality. If photo documentation is to form part of the medical examination, the patient should be advised in ad- vance of the means of storage and its potential uses (see Subheading 2. Details of the Allegation If the complainant has already provided the details of the allegation to another professional, for example, a police officer, it is not necessary for him or her to repeat the details to the forensic practitioner.
In a controlled study of 45 men buy prednisolone on line amex, increased nighttime urinary frequency was relieved or reduced in 95% discount generic prednisolone uk, urgency reduced in 81% order cheap prednisolone line, daytime urinary frequency reduced in 73%, and delayed urination alleviated in 70%. Every effort should be made to decrease cholesterol levels by using the principles outlined in the chapter “High Cholesterol and/or Triglycerides,” as well as to prevent the formation of toxic forms by maintaining a high intake of dietary antioxidants. Soy Products Soybeans are especially rich in phytosterols, especially beta-sitosterol. A recent double-blind study consisted of 200 men receiving beta-sitosterol (20 mg) or placebo three times per day. Increased consumption of soy and soy foods is also associated with a decrease in the risk of prostate cancer (see the chapter “Prostate Cancer [Prevention]”). Other popular botanical medicines include pygeum (Pygeum africanum), stinging nettle (Urtica dioica), and Cernilton, a special ﬂower pollen extract. On the basis of careful examination of the published literature, we rate saw palmetto as the most effective, followed by Cernilton, pygeum, and stinging nettle. However, each plant has a slightly different mechanism of action, and one herb may work better for a particular person than another herb. Residual urine levels between 100 and 150 ml will make it tougher to see signiﬁcant improvements. If the residual urine content is greater than 150 ml, saw palmetto extract and other botanical medicines are unlikely to produce any significant improvement on their own. Over the years many of us in the natural health ﬁeld have seen the media disseminate questionable results from research studies in major medical journals, holding them up as “proof” that the public is being duped into spending money on worthless natural products. Of course, those knowledgeable about the merits of these same natural products try to mobilize the resources that we have available to counteract these negative statements, but this is often difﬁcult when we are up against an article published in a respected journal such as the New England Journal of Medicine, Lancet, British Medical Journal, or Journal of the American Medical Association. Such journals are seemingly more credible than even the natural product industry’s most reputable organizations, companies, and experts. The problem is that the study that got a lot of publicity was done in men with severe, advanced disease, in which saw palmetto is already known not to work. The media did not make this distinction, simply asserting that saw palmetto does not work. If a man waits until his prostate has enlarged so severely that it results in signiﬁcant obstruction of the bladder, saw palmetto is simply not likely to work. But if he starts it early enough, it is as effective as or more effective than popular prescription drugs without the side effects. Adverse effects from the saw palmetto extract were mild and infrequent, with erectile dysfunction appearing more frequently with ﬁnasteride (4. Future studies will hopefully include head-to-head trials comparing saw palmetto with alpha-blockers such as tamsulosin (Flomax), doxazosin (Cardura), and prazosin (Minipress). In addition, Cernilton contains a substance that inhibits the growth of prostate cells. They saw improvements in average urine maximum ﬂow rate, average ﬂow rate, and residual urine volume. Overall, 85% of the test subjects experienced beneﬁt: 11% reporting “excellent,” 39% reporting “good,” 35% reporting “satisfactory,” and 15% reporting “poor” as a description of their outcome. A summary review of two placebo-controlled studies, two comparative trials (both lasting 12 to 24 weeks), and three double-blind studies of 444 men showed that although Cernilton did not improve urinary ﬂow rates, residual volume, or prostate size, it did improve self-rated urinary symptom scores and reduced nighttime urinary frequency compared with a placebo and an amino acid mixture. Pygeum The bark of Pygeum africanum, an evergreen tree native to Africa, has historically been used in the treatment of urinary tract disorders. Virtually all of the research on pygeum has featured an extract standardized to contain 14% triterpenes, including beta-sitosterol and 0. This extract has been extensively studied in both experimental animal studies and clinical trials with humans. A study on rat prostatic cells suggests that the therapeutic effect of pygeum may be due in part to the inhibition of growth factors (e. However, there may be circumstances where pygeum is more effective than saw palmetto. For example, saw palmetto has not been shown to produce some of the effects on prostate secretion that pygeum has. Of course, as the two extracts have somewhat overlapping mechanisms of actions, they can be used in combination. Fewer studies have been done with stinging nettle root extract than with the other botanical medicines discussed. A randomized, multicenter, double-blind study of 431 patients using both the extracts of saw palmetto and stinging nettle found clinical beneﬁt equal to that of ﬁnasteride. It is important to limit the consumption of meat and other animal products; alcohol and coffee; drug-, pesticide-, and hormone-contaminated foods; and cholesterol-rich foods. It affects few blacks in tropical zones but is more common among blacks in temperate zones. It appears commonly among Japanese but is rare in American Indians and is entirely absent in natives of the Andean region of South America. The nails take on a characteristic thimble-like appearance referred to as “oil drop” stippling. Causes Psoriasis is caused by a pileup of skin cells that have replicated too rapidly. The rate at which skin cells divide in psoriasis is roughly one thousand times greater than in normal skin. This high rate of replication is simply too fast for the cells to be shed, so they accumulate, resulting in the characteristic silvery scale of psoriasis. The frequency of psoriasis is increased in people with certain genetic markers, reﬂecting a possible genetic error in the control over how skin cells divide. The genetic link is also conﬁrmed by the observation that 36% of psoriasis patients have one or more family members with psoriasis. There are also multiple defects noted in the skin and immune cells of psoriatic patients, indicating a complex interplay of genetic factors. It appears that rather than being a disorder of the skin cells, psoriasis is primarily a condition that affects the immune system. There is a clear relationship between psoriasis and conditions associated with altered gastrointestinal permeability, such as celiac disease10 and Crohn’s disease, 11 and in conditions associated with impaired liver function. Therapeutic Considerations Although psoriasis has a signiﬁcant genetic component, addressing the factors that can activate the immune system or skin cells can result in significant clinical improvement. Incomplete Protein Digestion Incomplete protein digestion or poor intestinal absorption of protein breakdown products can result in elevations of amino acids and polypeptides in the bowel. In particular, toxic metabolites of the amino acids arginine and ornithine, known as polyamines (e. These polyamines have been shown to contribute to the excessive rate of cell proliferation in psoriasis. For example, vitamin A and the alkaloids of goldenseal (Hydrastis canadensis) such as berberine inhibit bacterial decarboxylase, the enzyme that converts amino acids into polyamines. See the chapter “Digestion and Elimination” for more information, as ensuring proper digestion is a key step in dealing with psoriasis.
In these “barren” regions of the genome purchase prednisolone 40 mg amex, the transgene is subject to silencing or extinction buy 20mg prednisolone otc. An obvious solution to these problems is to attempt to direct or target the trans- gene toward a speciﬁc site in the genome 40 mg prednisolone free shipping. This simple concept was contemplated several decades ago but was considered unattainable until the early 1980s. Once a recombinogenic transgene localizes to the nucleus, its likely fate is to integrate ran- domly. Early experiments in human cells suggested that homologous recombination (site-speciﬁc integration) was feasible but rare. This tech- nology has now been considerably enhanced and applied to over 300 different genes in murine and human cells. This advance, though heartening for a variety of research applications, has not resulted in a signiﬁcant improvement of the actual frequency of gene conversion. Deﬁciency in one or more rate-limiting steps must be responsible for the inefﬁciency of targeting. Since over 2000 human diseases have been mapped at the level of their genetic defects and most of them are caused by mutations in the coding regions of a single gene, the most elegant solution is to repair the gene in situ, that is, correct the defect in a living cell either by repairing a nucleotide mutation or by replacing the entire gene. The reality of that challenge, however, has intimidated workers and hindered progress. This process is widely described as “gene trans- fer,” but as with many terms in modern science, it is overused and often abused. Finally, it may integrate into the host cell’s chromosome and become a stable, permanent, or in rare cases, an unstable part of the genome. The termini of each molecule are attractive substrates for nucleases, and their action may lead to complete degrada- tion. Upon entering the nucleus it could remain episomal or become integrated into the chromosome, an event that occurs rarely at the homologous site in the genome. These two groups of compounds alter the electrophysiological environment of the cell’s membrane, reducing the electrostatic repulsion and increasing membrane pore size. Although these methods are somewhat labor intensive, they are quite effective and used routinely in many laboratories. More often though, lipid formulations, known as liposomes are used in gene transfer protocols when viral delivery is not an option. Certain viruses insert themselves into a host’s chromosomes and become contiguous with the host genome. In fact, one of the challenges facing workers in the gene targeting ﬁeld is to reduce the randomness of retroviral integration while maintaining the explosive infection rate. It is often the endpoint the investiga- tor hopes to achieve that dictates which method will be used. The transfer of a normal gene in the perfect situation will, in all likelihood, be carried out by a viral vector where the number of infectious agents and potential of each cell receiving at least one copy of the gene is high. As described above brieﬂy, there is always a limitation on the production levels of biological material and a chance that genetic exchange or recombination events will create a nondesirable or nonusable vector. An alternative gene transfer strategy employs lipid-based formulations known as liposomes. The development of this strategy has been driven, in large part, by the biotechnology industry. Among the diverse types of liposomes available are those that fuse with the phospholipid bilayer of the cell’s membrane and those that can avoid being sequestered in the cytoplasm by pathways that eliminate their effec- tiveness in gene delivery to the nucleus. To trans- fer foreign genes into a cell using a viral vector, the gene must be inserted into the viral genome, which often requires complicated cloning strategies. Beyond liposomes, success has been achieved when nucleic acid is introduced using physical force. These particles are accelerated by a gene delivery system (electrical or gas pulse) and sent into the target tissue. The efﬁciency of transfer, however, is variable and often dependent on the biophysical nature of the membrane. The latter method centers around the direct injection of material into the tissue by a ﬁne needle or syringe. But, the expression of genes on injected plasmids can persist for 60 days, espe- cially in muscle tissue, and cell regeneration activated at the site of injection can improve efﬁciency of uptake. Although both methods are important experimental systems, where the aim may be an assessment of plasmid construct expression, it is unlikely that a practical use for these approaches in the current gene therapy world will be found. Finally, electroporation of mammalian cells is becoming a standard- ized and useful technique. In the ideal situation the cloned gene is returned to its homologous location in the genome and becomes inserted at the target locus. The paradigm for thinking about the mechanism of this process has come primarily from two sources: (1) Principles of reaction mechanics have come from detailed biochemical analyses of proteins puriﬁed from Escherichia coli. Much less is known about the biochemical pathway leading to homologous recombination in most other experimental systems. Autonomously replicating plasmids containing gaps of several hundred nucleotide residues within the cloned gene also transform at high efﬁciency and are repaired by recombination using chromosomal information as a template. Unfortunately, the limited biochemical data available from yeast and the often confusing and sometimes contradictory results from the genetic studies have not provided a thorough foundation for experimentation. It is not completely clear from the transformation studies carried out that information on genetic control of plasmid integration will be generally applicable to higher eukaryotic systems under study by investigators interested in gene targeting. Transition to Higher Eukaryotes Recombination between plasmid and chromosome in higher eukaryotes has been exploited in numerous experimental systems where the aim is to inactivate or to replace a gene of interest (Fig. This process is often viewed as a nuisance by investigators whose priority, generally speaking, is in “knocking out” the gene of interest rather than in understanding the mechanism of the process. Conversely, the virtual absence of this illegitimate pathway of integration in the more genetically amenable sys- tems of yeast and bacteria has precluded investigation into its molecular mecha- nism. Therefore, strategies for gene targeting have for the most part evolved by the empirical method with only limited guidance from recombination theory or mechanism. It is likely that the failure to achieve high levels of gene targeting in mammalian cells is related directly to the low frequency of homologous recombi- nation. As described above, efforts to overcome this barrier have focused on the development of genetic enrichment methods; but these methods only eliminate non- homologous events, and they do not improve the frequency of homologous events. Experimental evidence points to the fact that the enzymatic machinery required to catalyze homologous targeting is limiting in mammalian cells. Such data lead to the hypoth- esis that targeting frequencies mammalian cells vary among cell types due to the unpredictable levels of enzymatic components within these cells. These discoveries provide good examples of how studies in lower organisms impact human biology and con- tribute to the development of therapeutic strategies. Homologs of the recA protein from yeast to humans have been discovered, although some of these proteins require auxiliary factors for activity and display unique characteristics. The power of the recA protein in promoting homologous recombination in prokaryotes led investigators to outline strategies for gene targeting in other cells based on its activity (Fig. By and large, this approach has not proven success- ful due to the differences between prokaryotic and eukaryotic pathways.
Experimental studies in tion caused by dead nematodes have been reported at all doses in chickens suggest that a dose of 1 order cheap prednisolone line. Commonly mixed in ever purchase prednisolone online pills, there is no work to confirm a positive immunostimulatory the food of geese and pheasants discount prednisolone uk. This drug is not recommended for use in administration or as an injectable suspension (100 mg/ml, Depo- debilitated patients. Intramuscular injection therapeutic dose may cause vomiting, neurologic problems and may cause muscle necrosis. Inhibits secretion of pituitary gonadotropin and ataxia, depression, regurgitation and mydriasis in some cockatoos, prevents follicular development and ovulation. Clinical signs are most severe when dose may be effective in suppressing ovulation for six months. Can be mixed with drinking to be very sensitive and require a reduced dose (see Chapter 29). Has been associated with birth defects when adminis- should be slowly weaned off the drug by a gradual reduction in tered to pregnant mammals. Not absorbed from the gastrointestinal mammals, stimulates gastrointestinal motility without increasing tract. Drug preparation used mainly for sterilizing the gut in gastric, biliary or pancreatic secretions. Some preparations may also contain other antibiotics, steroids, Has been associated with hyperactivity in some birds. The preparations containing trypsin be used when gastrointestinal stasis is caused be intraluminal or and chymotrypsin are particularly useful for debriding and provid- extraluminal masses that are preventing the movement of ing antimicrobial activity to necrotic areas of skin. Causes the expulsion of the parasite, Available as tablets (250 or 500 mg) for oral administration or as which can be a diagnostic aid in difficult-to-detect infections. Used ground tablets are not soluble in water and must be added to a for treatment of giardia, hexamita and for anaerobic bacterial gruel. Resistant organisms may require two daily injections tion to finches in Australia. Injectable solution can be adminis- in pigeons, geese and some other Anseriformes. If stration or as an ointment or cream (1 or 2%) for topical admini- neurologic signs occur, treatment should stop immediately. Used for the treatment of systemic mycosis, particularly of 1 tsp/gallon of drinking water may cause screaming, incoordina- candida and cryptococcus. Must be given slowly to prevent tachy- tion, vomiting, and death in mynahs, lorikeets and lories. High therapeutic index in mam- powder should not be used on wounds that could be open to the mals. Has been shown to be safe in cranes at five times the mood elevator to treat depression. If a bird becomes hyperactive, the amprolium for treating coccidiosis in Galliformes and cranes. May drug dose should be reduced and if it remains hyperactive, treat- be lethal if consumed by mature turkey or guinea fowl. Clinical experience suggests that this drug is rarely effective in cases of feather picking. If candida is found to be proliferating, nystatin therapy aminoglycoside administration. Some strains of candida are resistant to nys- Piperacillin is unstable (48 hours when refrigerated) once it is tatin and Gram’s stains should be used to monitor therapeutic reconstituted. Nystatin feed premixes contain high levels of calcium and should not be used in conjunction with tetracycline therapy (see Chapter 17). Should not be used Available as tablets (23 or 34 mg) for oral administration or as an if an egg is adhered to the oviduct, if the uterus is ruptured or if injectable solution (56. Can be mixed with food or administered by Available as a tablet (5 mg) for oral administration or as an gavage. Used as an anti-inflamma- assisting in the digestion of high-cellulose diets consumed by tory in cases of shock and trauma. Also effective in reducing the effects of endotoxins re- One-fourth of a tablet may be mixed with water or hand feeding leased from the destruction of gram-negative bacteria. Used in combination with chloroquine Synthetic, non-depolarizing, neuro-muscular blocking agent used for the treatment of avian malaria (Plasmodium sp. Should not be used in small birds because of a high mg/ml) for oral administration. Has a peripheral anticholinergic, incidence of procaine overdose and death in these species. Should not be used in of 1 mg/kg has been associated with paralysis and death in some patients with gastrointestinal blockage. Therapy for lice is the primary indication for ulcerated mucosa from gastric acids and microbial pathogens. Lice frequently inhabit the axillary regions, and the wings Indicated in cases of gastrointestinal bleeding. Repeated use of sulfonamides can induce hypersensiti- plasmodium, toxoplasma and sarcocystis. Effective for the treatment of Haemoproteus; reproductive activity and for some cases of feather loss. May be however, this parasite is not currently considered to be pathogenic, useful in some cases of reproductive-associated feather picking and treatment is not recommended. Contraindi- of 50-150 mg/kg (five times the recommended dose) causes hepato- cated in cases of renal or liver disease. Five drops of the stock solution is added to one oz of drinking water and is mixed fresh daily. Available as a soluble powder, capsules (250 mg), suspension or solution (100 mg/ml) for oral administration. Used in heavy metal poisoning to prevent absorption Available as a suspension (4 mg/30 ml) for oral administration. May be Should not be used in cases with impaired gastrointestinal func- toxic in ostriches, diving ducks and cranes. Used with some success for the flock (Galli- formes) treatment of enteritis caused by gram-negative bacteria. Lower concentration Salicylic acid (3 g), tannic acid (3 g) qs in ethyl alcohol to 100 ml. Good activity against many Pseudomonas Used as a topical treatment for moist and fungal dermatitis. Good synergistic effect with amino- glycosides for use in difficult-to-treat gram-negative bacteria.