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By W. Uruk. Dowling College.

Prevention of Contamination To ensure that there is no accidental transfer of body fluids or fibers between the parties who have been involved in a sexual act cheap super cialis 80mg without a prescription, each complainant and each suspect should be transported in separate vehicles and examined in different locations by different forensic practitioners cheap 80 mg super cialis with mastercard. There- fore 80 mg super cialis overnight delivery, gloves must be worn throughout the forensic examination and changed when sampling different body areas. In addition, the forensic physician should avoid talking, coughing, or sneezing over unsealed samples and should handle all samples as little as possible. If a doctor believes that there is a possibility that he or she will cough or sneeze over an unsheathed swab, a face mask should be worn when the sample is being obtained. Collection of Forensic Samples The swabs and containers used to collect forensic evidence differ from those used in clinical tests. The quality and integrity of any swab or con- tainer used to obtain a forensic sample must be ensured. The provision of sealed, standardized clinical forensic examination kits or modules ensures that these requirements can be guaranteed (8,9). Blood and urine samples for drug and alcohol analysis should be placed in containers with a preservative that prevents decomposition and fermentation (e. Because many of the samples are subsequently frozen, all the containers should be shatterproof. However, if storage space is restricted, then any used proctoscopes or specula may be swabbed and only the swabs retained for later forensic sampling. Sterile water may be used to moisten the proctoscope/speculum to facili- tate its insertion into a body orifice. Other lubricants should not be used when body fluid analysis or lubricant identification may be pertinent to the case (see Heading 11 on Lubricants). Controls An unopened swab from each batch should be retained and sent with the samples as a control for that batch of swabs. If any water is used in the sampling process, the remaining water in the ampule or an unused swab moistened with some of the water should be retained as a control sample for the water. Packaging and Continuity Any retrieved items must be packaged quickly and efficiently to prevent accidental loss of material and minimize decomposition of the sample. The use of bags with integral tamper-evident seals is recommended to prove that the sample has not been contaminated with exogenous substances since it was sealed. The exhibit should be labeled with the site of the sample, the date and time (24-h clock) it was obtained, and the name of the examinee. Again, the use of bags with integral labels will prevent accidental detachment of this vital information (see Fig. Each exhibit is also labeled with an exhibit identification code, usually formed by the forensic practitioner’s initials and a number reflecting the order in which the samples were obtained. The latter is particularly important when more than one sample has been obtained from the same site (7). Every exhibit should be signed by the person who first handled Sexual Assualt Examination 67 Fig. It is good practice for others who subsequently handle the exhibit to sign the label also, so that, if necessary, they can be called to court to explain their part in collection, transport, and storage (10). Clothing should be placed in bags made of material, such as paper, that prevents the accumu- lation of condensation, which could accelerate decomposition of body flu- ids. When the clothing is overtly wet or possibly contaminated with accelerants, the forensic science laboratory should be asked for advice on packaging and storage. The following additional information should then be recorded on the appropriate label: • Which items were worn during the offense. The forensic scientist must be provided with salient information regard- ing the incident and subsequent actions of the complainant in order to deter- mine the type of forensic analysis required. Their abundance and hypervariability make them ideal markers for the identification of an indi- vidual. As yet, it is unclear how useful this tool will be in the forensic setting (see Subheadings 5. The technique is best suited to discrete samples, such as hairs without roots and fecal material, and is not ideal for mixtures of body fluids, particularly when the complainant’s body fluid is likely to be present in larger quantities than that of the assailant (Tully, G. Therefore, in sexual offenses, the selection of material to be analyzed by this technique is limited and its use needs careful consideration. The forensic science laboratory must be notified when it is alleged that people who are closely related have been involved in a sexual offense, because their profiles will have greater similarity than profiles from individuals picked at random, and further differentiating tests may need to be performed. Method of Sampling All areas of unwashed skin that have been licked, kissed, sucked, bitten, or ejaculated on by either the assailant or the complainant must be sampled. There- fore, when dealing with an assault conducted by an unknown assailant, con- sideration should be given to sampling marks or injuries on the skin that the complainant attributes to direct contact by the offender. However, the prob- lem with this type of sampling is there is considerable lack of understanding about issues of transfer and persistence (24). Consequently, speculative skin swabbing in the absence of visible marks or injuries is not recommended. Although several techniques, including the use of surgical gauze pads (25) and cigarette papers (26), have been employed to recover saliva and other trace evidence from the skin with variable success, the use of sterile swabs is the most widely used technique that has received international endorsement (27).

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In case-controlled studies generic super cialis 80mg with visa, patients with type 1 were more likely to have been breastfed for less than three months and to have been exposed to cow’s milk or solid foods before four months of age super cialis 80mg low price. A critical review and analysis of all relevant citations in the medical literature indicated that early cow’s milk exposure may increase the risk about 1 purchase super cialis 80mg on line. There is also considerable evidence that sensitivity to gluten—the major protein component of wheat, rye, and barley—may also play a role. Celiac disease, like type 1 diabetes, is associated with intestinal immune function abnormalities. And, as with diabetes, breastfeeding appears to have a preventive effect, while the early introduction of cow’s milk is believed to be a major causative factor. Not surprisingly, the highest levels of antibodies to cow’s milk proteins are found in people with celiac disease. All of these viruses replicate in the gut and cause stimulation of the intestinal immune system; this may activate the insulin-specific immune cells to seek out and destroy beta cells. These viruses and others are also capable of infecting pancreatic beta cells, causing the leukocytes to attack and destroy the beta cells in an attempt to kill the virus. Another possibility is that gastrointestinal virus infections may increase intestinal permeability, leading to absorption of the intact protein; this then enhances the antibody response to dietary bovine insulin. The severe “leaky gut” or increased small-intestine permeability that occurs during and for some time following rotavirus infections (one of the most common causes of acute diarrheal illness in children) exposes the gut-associated immune cells to large quantities of intact proteins. Vitamin D Deficiency Emerging evidence indicates that vitamin D supplementation from cod liver oil and other sources during early childhood can prevent type 1 diabetes. One study found that the use of vitamin D from cod liver oil during pregnancy significantly reduced the frequency of type 1 in their children. Because vitamin D can be produced in the body by the action of sunlight on the skin, lack of sun exposure during childhood may also play a role and partially explain the higher type 1 rates in northern countries. In recent observational studies, vitamin D has been shown to prevent the development of autoimmune conditions, including attacks on beta cells; the degree of protection is dose dependent. The mechanisms responsible for this effect may be related to improved cell membrane function, leading to enhanced antioxidant status and suppression of the formation of inflammatory compounds known as cytokines. Nitrates are produced by agricultural runoff from fertilizers; they are also used in cured or smoked meats such as ham, hot dogs, bacon, and jerky to keep the food from spoiling. Infants and young children are believed to be particularly vulnerable to the harmful effects of nitrate exposure. One of the most alarming features of type 1 is that it is becoming much more prevalent, with a current growth rate of 3% per year worldwide. Increased nitrate exposure may be a key factor; nitrate levels in ground and surface waters of agricultural regions have increased over the past 40 years. Nitrate contamination occurs in geographic patterns related to the amount of nitrogen contributed by fertilizers, manure, and airborne sources such as automobile and industrial emissions. Nitrate exposure may explain why some geographic pockets have a substantially higher rate of type 1. Parents would do well to break the habit of feeding children hot dogs, cold cuts, and ham. Health food stores now carry nitrate-free alternatives to these rather toxic food choices. Also, investing in a high-quality water purifier is good insurance against ingesting nitrate-contaminated drinking water. Early Treatment and Possible Reversal of Type 1 Diabetes Early intervention in type 1 designed to affect the autoimmune or oxidative process theoretically may be capable of lengthening the “honeymoon” phase (the time before insulin becomes absolutely necessary) or even completely reversing the damage. Two substances that may have some benefit in this regard are niacinamide and epicatechin. Niacinamide The niacinamide form of vitamin B3 has been shown to prevent some of the immune-mediated destruction of pancreatic beta cells and may actually help to reverse the damage. In a study of newly diagnosed type 1 diabetics, seven patients were given 3 g niacinamide per day and nine were given a placebo. After six months, five patients in the niacinamide group and two in the placebo group were still not taking insulin and had normal blood glucose and hemoglobin A1C. At 12 months, three patients in the niacinamide group but none in the placebo group were in clinical remission. As of 2004, there had been 12 studies of niacinamide treatment in patients with recent-onset type 1, or type 1 of less than five years’ duration, and who still had some functional beta cells. Of 10 double- blind, placebo-controlled studies, 5 showed a positive effect compared with a placebo in terms of prolonging the period in which insulin was not yet required, lower insulin requirements when the hormone was required, improved metabolic control, and increased beta cell function as determined by secretion of a substance known as C-peptide. In the 5 studies that showed a positive result, patients had a higher baseline fasting C-peptide level, and patients were generally older than in the negative studies. The first of these studies, the Deutsche Nicotinamide Intervention Study, did not show much of an effect with 1. It is possible that such a formulation did not allow for sufficient peak levels of niacinamide to block autoimmune mechanisms. Nonetheless, the fact that some patients have had a complete reversal of their disease makes its use certainly worth the effort, especially since there is currently no other reasonable alternative. The dosage recommendation is based on body weight: 25 to 50 mg niacinamide per kg of body weight, up to a maximum dosage of 3 g per day, in divided doses.

The crop should not be overstretched buy super cialis 80 mg mastercard, as volumes more frequently during the healing process discount super cialis 80 mg amex. Mild cases of crop stasis caused by a dehydrated food Severe crop burns cause greater tissue damage proven 80 mg super cialis. In mass or overfeeding can often be solved by adminis- the early stages the crop will adhere to the overlying tering a small amount of warm water and gently skin; the skin will be hyperemic and the site may be massaging the crop. Eventually the crop may fistu- to five hours, the crop should be emptied and flushed late, and food and water will leak from the crop with warm saline. Crop fistulas are flush the crop, a lubricated soft feeding tube with an treated by removing the scab, surgically excising the open end is gently passed into the crop, and a small necrotic portion of the skin and crop and then sepa- amount of saline is flushed in and out to draw crop rating and individually closing the crop and skin (see material into the syringe. The timing of surgery is palpate the tube and direct it toward the food mass important. When moving or with- tated and should receive supportive care and enteral drawing the tube, negative pressure on the syringe alimentation to build their strength prior to anesthe- should be released to make sure the tube does not sia and surgery. The re- fistula should be given as much time as possible to moval procedure should be accomplished in stages if heal before surgery, and the scab should be left in the bird becomes overly stressed. Most birds with crop stasis are dehydrated and require parenteral fluid administration. A Gram’s stain of a crop swab can be used to determine the microbial agents that are present. If a generalized microbial infection is suspected, start treat- ment with a broad-spectrum antibiotic and antifungal drug. Cephalosporins and penicillins are the safest drugs to use; aminoglycosides and sulfas should be avoided due to poten- tial dehydration and renal toxicity. Injectable antibiotics should be used if there is severe stasis because oral antibi- otics would not be properly absorbed. Oral antifungals (nys- tatin) should be used because the parenteral antifungal drugs (eg, amphotericin B) may be toxic. If the bird has generalized ileus, a motility stimulant such as metoclopramide or D-panthenol can be administered. Once the crop starts to partially empty and the bird is stabi- hangs over the thoracic inlet where food cannot enter the thoracic lized, limited feeding should resume. A crop bra can be used to elevate the crop a liquid, complex carbohydrate, medium-fiber-content diet and increase the gravitational forces that encourage food to pass until the crop is emptying normally (see Chapter 15). Gerber’s through the thoracic portion of the esophagus and into the proven- oatmeal with applesauce and bananas baby cereal mixed triculus (courtesy of Kim Joyner). As the crop starts to empty normally, the diet that is normally fed should be gradually results in a reduced crop capacity. It is impor- the bird should be fed small amounts of food fre- tant to restore normal feeding as quickly as possible because dilute baby food diets do not provide sufficient nutrition for quently to prevent reflux and aspiration. Subcutaneous fluid administration and antibiotics amount of food offered can be gradually increased to should continue until the bird is clinically normal. If the crop is overstretched or atonic it is beneficial to apply a pharyngotomy tube may be necessary to allow feed- “bra” to elevate the crop and facilitate emptying (Figure ing yet protect the wound during healing. The bra can be constructed from elastic bandage material or baby tube socks and should be applied while the tive to a pharyngotomy tube is to place a mushroom- crop is full to make sure it is not too tight. The neonate should tipped jejunal catheter in the crop and tunnel it be confined to a small container for a few days if it objects to subcutaneously up the side of the neck. Parenteral nutrition would be beneficial in cases of crop should be covered with a permeable dressing and stasis; however, at the time of this publication this is still a allowed to heal as an open wound. Regurgitation Hand-fed birds (especially macaws and African Grey Parrots) commonly regurgitate at weaning, and it is 30. If surgery is attempted before the tissues important to differentiate this relatively normal phe- surrounding the burn have healed, it is difficult to nomena from a pathologic condition. Causes of regur- accurately assess the extent of devitalized tissue that gitation include overfeeding, crop stasis, alimentary must be debrided. Surgical adhesives can be used to tract infections (especially candidiasis), alimentary close the crop and allow feeding or a pharyngotomy tract foreign bodies, blockage of the alimentary tract tube can be passed (see Chapter 41). It has been and use of some drugs such as trimethoprim-sulfa estimated that it takes seven to ten days following a compounds and doxycycline. Large crop defects (greater than one-third the size of the crop) can be difficult to repair. Preventing neonates from consuming foreign Intestinal Intussusception bodies is far easier than treating them. The feeder should be very selective about the objects the birds This condition is occasionally reported in macaws are allowed to contact (Color 30. Mild cases are diagnosed radiographically object from entering the proventriculus. It is much and may respond to antimicrobial and supportive easier to retrieve objects from the crop than the therapy. Severe cases with a visible cloacal prolapse proventriculus, and birds have a remarkable capac- are usually fatal.

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At any given level of the trait being measured [in this case it is physical disability] the probability of response to the item differs significantly across countries order super cialis 80mg otc. Finally cheap super cialis 80mg overnight delivery, in Modern Test Theory discount 80 mg super cialis amex, the true scaling properties of the out- come measure can be revealed. In measurement terms, those points that mark the transition between one category and the next – thresholds – are critical to the process. Thus eight items with four categories have 24 thresholds, eight of each marking the transition between 0 and 1; 1 and 2, and 2 and 3. Fig- ure 3 shows how these thresholds are placed on the underlying metric scale (the lower part of the graph – the upper being the distribution of pa- tients). One patient may have to move only a small metric distance to gain, say, 5 points, another a considerable distance. Person and item distribution of ordinal scale after fitting data to the Rasch model. It becomes clear that both Traditional and Modern Test Theory bring together a set of parameters for judging the quality of outcome measures. Given the reliability and validity of an instrument, knowing the level of measurement of the scale is crucial to making proper use of the instru- ment. One way of overcoming this limitation it that, where data fit the Rasch model, ordinal scores are transformed to interval level logits. Ordinal data ‘are sel- dom in practice, and never in principle, sufficiently interval to justify arithmetical calculations employed by means, variance, regressions and factor analysis’ (27). Another important aspect of using outcome measures is what to do with missing values. These may be a particular problem for self-complet- ed questionnaires, but may also arise in professional administered instru- ments (e. Missing data may also arise through poorly managed quality control procedures at the data entry stage. However, once again, when data fit the Rasch model, estimates of person ability are obtained which are not affected by missing values [except by loss of precision in the esti- mate]. This conceptualisation of the appropriate outcome space enables a choice of relevant instruments. All such instruments should meet the classical psychometric requirements of reliability, validi- ty and responsiveness. Increasingly, such instruments should also demon- strate adequate internal construct validity [unidimensionality] and free- dom from item bias. Once the data have been collected, appropriate ana- lytical techniques should ensue that the findings are not compromised through the inappropriate use of arithmetic operations and choice of the wrong statistical procedures (29). The genesis of handicap: definition, models of disablement, and role of ex- ternal factors. Factors determining participation in young adults with a physical disability: a pilot study. Health status as a measure of health promotion and disease prevention: un- resolved issues and the agenda for the 1990’s. Importance of sensitivity to change as a criterion for selecting health status measures. Dimensionality of an early childhood scale using Rasch analysis and confirmatory factor analysis. Physical Medi- cine and Rehabilitation: State of the Art Reviews 1997; 11(2): 375-384. Guidleines to statistical evaluation of data from rating scales and question- naires. An outcome measure is essentially an assessment of change which judges how the patient is now as compared with previously, in order to study the effect of the health care process on the patient’s health and well-being (4). This assessment often involves the determination of the meaning of a measurement, defined as the process of assigning numerals (or categor- ical names) to variables to represent quan- tities of characteristics according to cer- tain rules (5). Many measures have been used in or- thopaedics and rheumatology to assess outcome in all forms of intervention (1, 3). This paper reviews the literature and discusses, in particular, the ma- jor issues regarding measures of physical function (e. The most common formats (1-4) used for measurement (alone or in combination) are: a) observation/examination – when health profession- als (or others) make a judgement and rate some parameters on the basis of subjective evidence and with minimal input from the patient; b) patient report – in the form of a structured interview or, more often, of a self-com- pletion questionnaire in which the client is asked to report, with minimal influence from other persons, experienced phenomena (such as pain, dis- tress, fatigue and so on), or give a relativistic evaluation correlated to his/her perspectives/expectations (e. Sometimes, a proxy/caregiver account is collected when the client cannot self-report or when the examiner is interested also in alternative information. The concept of interest can be measured by a single question, rating or item (summary item) or – more often – by a series of them. When the component ratings are presented separately for each di- mension, a “profile” is formed.

Techniques to help you learn to be more optimistic are given later in this chapter cheap super cialis 80mg free shipping. Attitude buy 80mg super cialis overnight delivery, Personality super cialis 80mg online, Emotions, and Immune Function The importance of attitude to human health has been demonstrated in the links between the brain, emotions, and immune system. Research in the field of psychoneuroimmunology indicates that every part of the immune system is connected to the brain in some way, either via a direct nervous tissue connection or through the complex language of chemical messengers and hormones. What scientists are discovering is that every thought, emotion, and experience sends a message to the immune system that either enhances or impairs its ability to function. A simplistic view is that positive emotions, such as joy, happiness, and optimism, tend to boost immune system function, whereas negative emotions, such as depression, sadness, and pessimism, tend to suppress it. These include a positive mental attitude, an effective strategy for dealing with stress, and a capacity to effectively deal with life’s traumas and challenges. The relationship of explanatory style (optimistic or pessimistic) to incidence of coronary heart disease was examined as part of the Veterans Affairs Normative Aging Study, an ongoing cohort study of older men. Interestingly, a clear dose-response relationship was found between levels of optimism and each outcome. To illustrate how closely the cardiovascular system is linked to attitude, one study showed that measures of optimism and pessimism affected something as simple as ambulatory blood pressure. Excessive anger, worrying, and other negative emotions have also been shown to be associated with an increased risk for cardiovascular disease; however, these emotions may simply reflect a pessimistic explanatory style. Attitude and Self-Actualization A positive mental attitude is absolutely essential for us to really live life to the fullest. There appears to be an innate drive within each of us to achieve the experience of self-actualization in our lives. Self-actualization is a concept developed by Abraham Maslow, the founding father of humanistic psychology. His theories were the result of intense research on psychologically healthy people over a period of more than 30 years. Maslow was really the first psychologist to study healthy people, as he strongly believed such research would create a firm foundation for the theories and values of a new psychotherapy. Maslow developed a five-step pyramid of human needs in which personality development progresses from one step to the next. The needs at the lower levels must be satisfied before the next level can be achieved. The primary needs that form the base of the pyramid are basic survival or physiological needs— the satisfaction of hunger, thirst, sexual desire, and the need for shelter. The final step is self-actualization—the utilization of one’s creative potential for self-fulfillment. Maslow studied self-actualized people and noted that they had strikingly similar characteristics. Self-actualized people perceive reality more accurately and effectively than others and are more comfortable with it. They possess an ability to be objective about their own strengths, possibilities, and limitations. This self-awareness enables them to clearly define their values, goals, desires, and feelings. They do not have an absolute lack of guilt, shame, sadness, anxiety, or defensiveness, but they do not experience these feelings to unnecessary or unrealistic degrees. Generally, they will feel bad about discrepancies between what is and what ought to be. Self-actualized people are relatively spontaneous in their behavior, and far more spontaneous than that in their inner life, thoughts, and impulses. They seldom allow convention to keep them from doing anything they consider important or basic. Self-actualized people have a problem-solving orientation toward life instead of an orientation centered on self. They commonly have a mission in life, some problem outside themselves that enlists much of their energies. In general, this mission is unselfish and is involved with the philosophical and the ethical. It is often possible for them to remain above the battle, to be undisturbed by things that upset others. The meaning of their life is self-decision, self-governing, and being an active, responsible, self-disciplined, deciding person rather than a helpless pawn ruled by others. Self-actualized people have a wonderful capacity to appreciate again and again the basic pleasures of life such as nature, children, music, and sexual experience. They approach these basic experiences with awe, pleasure, wonder, and even ecstasy. Self-actualized people commonly have mystic or “peak” experiences, times of intense emotion in which they transcend self. During a peak experience they have feelings of limitless horizons, feelings of unlimited power, and at the same time feelings of being more helpless than ever before. There is a loss of place and time, and feelings of great ecstasy, wonder, and awe.

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The subjects kept track of symptoms such as cough buy super cialis 80 mg low cost, headache super cialis 80mg on line, hoarseness order super cialis 80 mg mastercard, muscle ache, nasal drainage, nasal congestion, scratchy throat, sore throat, sneezing, and fever. The time to complete resolution of symptoms was significantly shorter in the zinc group than in the placebo group. The formulation in this study differed from those in the studies that did not show much benefit from zinc lozenges; the lack of benefit in the latter group of studies may have been due to an ineffective lozenge formulation. The explanation for this can be found in an interesting study that evaluated the actual amount of ionized zinc released into the saliva by various lozenges. The study showed that sucking on hard candy lozenges containing zinc gluconate and citric acid delivered an insignificant amount of ionized zinc. Certain sweetening agents such as mannitol and sorbitol also prevent the ionization of zinc. The best zinc lozenges are those that provide zinc acetate or gluconate and do not contain citric acid, mannitol, or sorbitol. In contrast to citric acid, mannitol, or sorbitol, glycine—even in excessively large amounts—was found not to interfere with ionization of zinc. In order for a zinc lozenge to be effective, it must be free from sorbitol, mannitol, and citric acid. Echinacea There have been more than 300 scientific investigations on the immune-enhancing effects of echinacea—one of the most popular herbs in the treatment of the common cold. Mixed results from clinical studies with echinacea are most likely due to lack of or insufficient quantity of active compounds. The effectiveness of any herbal product depends on its ability to deliver an effective dosage of active compounds. For example, in one double- blind study 160 subjects were given either echinacea or a placebo and then exposed to a common cold virus. Infection occurred in 44 and 57% of the echinacea- and placebo-treated subjects, respectively, and illness occurred in 36 and 43%. However, the preparation lacked the active components of echinacea—it contained no echinacosides or alkamides and only 0. They were instructed to start the echinacea or placebo at the onset of the first symptom related to a cold, consuming 10 doses the first day and 4 doses per day on subsequent days for seven days. Severity of symptoms was recorded each day, and a nurse examined the subjects on the mornings of days three and eight. Throughout the treatment period, the response rate to treatments was greater in the echinacea group. Again, to highlight the issue of quality control and source of preparation, several studies with less well-defined echinacea products showed little benefit, especially in experimentally induced rhinovirus infections. The main outcome measure was time until the first upper respiratory tract infection. The secondary outcome measures were the number of participants with at least one infection, global assessment, and adverse effects. The time until occurrence of the first upper respiratory tract infection was 66 days in the E. These results indicate that there was no significant benefit with either form of echinacea, although there was an approximately 20% reduced risk of infection in the echinacea groups. In one of the most detailed clinical trials, 719 patients were assigned to one of four groups: no pills, placebo pills (blinded), echinacea pills (blinded), or echinacea pills (unblinded). Echinacea groups received 8 tablets on the first day and 4 tables on the subsequent four days. Each tablet contained the equivalent of 675 mg alcoholic extract of dried Echinacea purpurea root and 600 mg alcoholic extract of Echinacea angustifolia root; the placebo group received the same number of tablets. The results showed only a statistically insignificant trend in reduction of the cold duration (half a day) and a reduction of severity of approximately 10%. Clinical studies of upper respiratory tract infections treated with extracts of fresh Echinacea purpurea whole plant or aerial plant, especially in liquid form, are consistently positive compared with those using dried echinacea extracts or powdered herbs, especially in solid forms (tablets or capsules). It is possible that echinacea may exert direct local effects and that contact with lymphatic tissue in the mouth and throat is extremely important in an upper respiratory tract infection. Reasonably large and well-designed, double-blind, placebo-controlled studies have found that preparations of echinacea from the aerial portion of the plant produce modest effects in staving off colds as well as reducing symptoms and duration. The length of time between infections was 40 days with echinacea, 25 days with the placebo. When infections did occur in patients receiving echinacea, they were less severe and resolved more quickly. The results from another trial were especially encouraging, as they suggested that echinacea can not only make colds shorter and less severe but also sometimes stop a cold that is just starting.

A doctor will usually be allowed to refer to any notes made contemporaneously to “refresh his memory cheap 80 mg super cialis otc,” although it is courteous to seek the court’s agreement generic super cialis 80 mg overnight delivery. Demeanor in Court In the space available order super cialis 80 mg without a prescription, it is not possible to do more than to outline good practice when giving evidence. Court appearances are serious matters; an individual’s liberty may be at risk or large awards of damages and costs may rely on the evidence given. The doctor’s dress and demeanor should be appro- priate to the occasion, and he or she should speak clearly and audibly. As with an oral examination for medical finals or the defense of a writ- ten thesis, listen carefully to the questions posed. Think carefully about the reply before opening your mouth and allowing words to pour forth. Answer the question asked (not the one you would like it to have been) concisely and carefully, and then wait for the next question. There is no need to fill all silences with words; the judge and others will be making notes, and it is wise to keep an eye on the judge’s pen and adjust the speed of your words accordingly. Pauses between questions allow the judge to finish writing or counsel to think up his or her next question. If anything you have said is unclear or more is wanted from you, be assured that you will be asked more questions. Be calm and patient, and never show a loss of temper or control regard- less of how provoking counsel may be. An angry or flustered witness is a gift to any competent and experienced counsel, as is a garrulous or evasive wit- ness. Stay well within your area of skill and expertise, and do not be slow to admit that you do not know the answer. Your frankness will be appreciated, whereas an attempt to bluff or obfuscate or overreach yourself will almost certainly be detrimental to your position. Doctors usually seek consensus and try to avoid confrontation (at least in a clinical setting). They should remember that lawyers thrive on the adversarial process and are out to win their case, not to engage on a search for truth. Thus, lawyers will wish to extract from witnesses answers that best sup- port the case of the party by whom they are retained. However, the medical witness is not in court to “take sides” but rather to assist the court, to the best of the expert witness’ ability, to do justice in the case. Therefore, the witness should adhere to his or her evidence where it is right to do so but must be prepared to be flexible and to make concessions if appropriate, for example, because further evidence has emerged since the original statement was pre- pared, making it appropriate to cede points. The doctor should also recall the terms of the oath or affirmation—to tell the truth, the whole truth, and nothing but the truth—and give evidence accordingly. The essential requirements for experts are as follows: • Expert evidence presented to the court should be seen as the independent product of the expert, uninfluenced regarding form or content by the exigencies of litiga- tion (30). If the expert cannot assert that the report contains the truth, the whole truth, and nothing but the truth, that qualification should be stated on the report (32). In England and Wales, new Civil Procedure Rules for all courts came into force on April 16, 1999 (34), and Part 35 establishes rules governing experts. The expert has an overriding duty to the court, overriding any obliga- tion to the person who calls or pays him or her. An expert report in a civil case must end with a statement that the expert understands and has complied with the expert’s duty to the court. The expert must answer questions of clarifica- tion at the request of the other party and now has a right to ask the court for Fundamental Principals 57 directions to assist him in conducting the function as an expert. The new rules make radical changes to the previous use of expert opinion in civil actions. Most pit- falls may be avoided by an understanding of the legal principles and forensic processes—a topic of postgraduate rather than undergraduate education now. 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. Meticulous attention to detail and a careful documentation of facts are required at all times. You will never know when a major trial will turn on a small detail that you once recorded (or, 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.

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