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W. Topork. Pacific Union College.

The deeper injuries tend to reflect the use of greater force buy 400mg viagra plus visa erectile dysfunction medication for high blood pressure, but it is not possible to correlate with any degree of certainty the amount of force needed to cause a particular injury in any individual cheap viagra plus online visa young healthy erectile dysfunction. It is essential for both the forensic physician who examines a living vic- tim of a baton blow to the head (or from any other cause) and the pathologist who performs a postmortem examination to remember that significant cere- bral trauma can be caused in the absence of obvious external trauma or skull fractures, and it would be prudent to assess anyone who has received or com- plains of receiving a head injury from a baton or from any other cause and to consider carefully if referral to hospital for a full neurological assessment is advisable. Neck Holds Pressure on and around the neck is well-known to be a potentially lethal action (14). Death can be caused after compression of the neck by any one of four mechanisms or by any combination of two or more of the following: • Airway obstruction by direct compression of the larynx or trachea or by the pres- sure on the neck raising the larynx upward and causing the superior aspect of the pharynx to be occluded by the tongue base. This can be achieved by pressure of a forearm across the front of the neck, sometimes called the “choke hold. The low pressure in the venous system and the thin yielding nature of the vein walls make venous occlusion more easily achieved than arterial occlusion; however, the large reserve capacity of the venous system makes it unlikely that rapid death would result even if complete occlusion was achieved, unless some other factor supervened. This is harder to achieve than venous occlusion because of the higher pressure in the arterial system and the thick- ness of the arterial walls; however, the effects of occlusion will become apparent much quicker. Saukko and Knight (14) record that occlusion of the carotid circula- tion for 4 min or more may result in brain damage, and Reay et al. A sleeper hold is applied when the upper arm compresses one side of the neck and the forearm the other and the larynx rests in the “V” formed by the elbow. Vagal stimulation 340 Shepherd results in bradycardia, which may progress to asystole or, in some cases, imme- diate asystole. Conversely, Kowai (17) concluded that the use of the choke hold could take between 10 and 20 s to cause unconsciousness, and, therefore, it was safe. Clearly, they did not experience the vagal effects of this hold in their experiments. Neck holds are commonly used in many forms of wrestling or martial arts, and in these situations, they are seldom associated with fatalities, possi- bly because of the ability of the person held to indicate his or her willingness to submit to a referee and so cause the hold to be released. No such author- ity is present during a restraint by police; perhaps this is why fatalities are recorded in this situation. In the United Kingdom, the use of neck holds by police during restraint is specifically prohibited and officers are warned dur- ing their training of the potentially fatal effects of applying any pressure to the neck. The pathological examination of deaths associated with compression of the neck requires a detailed and careful dissection of the neck structures (18). The finding of injuries to the muscular, cartilaginous, vascular, or neural com- ponents of the neck must be interpreted in the light of the restraint events, the actions of the restrainers, and the subsequent resuscitation, if any. Pressure on the neck to maintain an airway after cardiac or respiratory arrest may result in bruising, which could be confused with pressure before or, indeed, causing that arrest. Therapeutic insertion of cannulae during active resuscitation by paramedics or in the hospital commonly leads to marked hemorrhage in the neck that, although it is unlikely to be confused with bruising caused by a neck hold, may mask any bruising that was present. Pressure on the neck is not, of course, the only mechanism whereby an individual may suffer anoxia or asphyxiation. Any action that partially or completely occludes the mouth and/or the nose will result in difficulty in breathing and may result in asphyxiation. The features of these other causes of asphyxiation, traumatic or restraint asphyxia, are discussed in Subhead- ing 11. Homicide There have been numerous cases where individuals have been murdered in the cell by another inmate. Such deaths are most commonly associated with blunt trauma, but strangulation, stabbing, and other methods may be employed Deaths in Custody 341 if suitable weapons are available. It is also evident that individuals have been deliberately assaulted and killed by police officers during arrest and detention. The forensic physician should always be aware of the possibility that police may have used excessive force or that deliberately homicidal injuries may have been inflicted. If injuries are present on any individual in their care, these injuries must be carefully documented and, if they are beyond that which the physician considers reasonable in the circumstances, their concerns should be expressed immediately to a senior officer, to a legal representative of the detainee, and an official complaints procedure. The physician also has the duty to ensure that no further harm comes to that person. The methods used are variable but reflect the materials available to the indi- vidual at that time. Hanging To effect a hanging suicide, the individual must have two things: an object that can be made into a noose and a point on which to tie it. In addition, the individual must be able to place his or her body so that his or her body weight can be used to apply pressure to the neck via the noose. The materials and objects that can be made into a noose are many and vary from the obvious (ties, belts, shoelaces, etc) to the unusual (underwear, shirts, etc). To attempt to reduce the possibility of hanging suicides many police station cells have been redesigned and attachment points for the noose (pipes, bars, etc) have been removed or covered. However, the lack of these obvious points did not deter some individuals who placed the bed on end and used the upper end as the fixing point. Installation of fixed beds or benching should preclude the use of that method in future. It must be remembered that hanging can still be achieved, although is clearly more difficult, from a low suspension point, and any protrusion from a wall or fitment in a cell can potentially be used as the upper attachment for the noose. In addition to removing the fixing points, attempts have been made to remove the items that have been used as nooses in the past and belts, shoelaces, etc. Paper clothing has been used, although this has not been entirely successful because it entails removing all of the individual’s clothing, which is clearly impractical in many cases and may raise problems with human rights. If made strong enough to withstand any degree of wear, the paper clothing would also be strong enough to act as a noose. Given the speed with which hanging can be effected, it is most unlikely that anything other than a permanent watch over the suicidal detainee would provide a foolproof method to prevent hanging in a cell. A cycle of 15-min- utes checks will allow more than ample time for an individual to hang himself or herself and cannot be considered to be adequate protection against this type of suicide. Ligature Strangulation Because the possibility of suspension is reduced by the changes in the design of the cells, the possibility of other forms of self-asphyxiation are likely to increase. Self-strangulation by ligature is considered to be possible but dif- ficult (14); because the pressure has to be applied to the neck in these cases by the conscious muscular effort of the hands and arms, it follows that when consciousness is lost and the muscular tone lessens, the pressure on the liga- ture will decrease, the airway obstruction and/or the vascular occlusion will cease, and death will generally be averted. However, if the ligature is knotted or if the material is “non-slip” and looped around itself, then it is possible for the individual to apply the pressure to the neck and for that pressure to be maintained even after consciousness is lost and, as a result, death may follow. As with hanging, the key to preventing these deaths lies in careful evalu- ation and, if necessary, the removal of clothing and observation. Incised Injuries All prisoners should be carefully searched before incarceration, and any sharp objects or objects that could be sharpened must be removed. The extent of the search will probably depend on the mental state of the individual, and the possibility of an intimate search to exclude weapons concealed in the vagina or rectum should be considered in those individuals who are considered most at risk. Even if the individual is found before death has occurred, the effects of pro- found blood loss may make death inevitable, despite resuscitation attempts. Drugs When considering the possibility of suicide using drugs while in police custody, the two key factors are, once again, evaluation and searching. Care- ful searching (possibly including intimate searches in some cases) will pre- vent the ingestion of drugs by an individual after he or she has been placed in Deaths in Custody 343 the cell.

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Mood disorders order viagra plus 400mg with mastercard erectile dysfunction in females, anxiety cheap 400 mg viagra plus visa erectile dysfunction boyfriend, poor motivation, fear of testing, and – most of all – depression, can impair cognitive performance. On the other hand, deliberately poor performance (malingering) in the course of a medico-legal assessment is usually easy to identify as unexpectedly low performances when evaluated in the context of daily functioning, or when errors do not make sense either in terms of usual patient test perfor- mances or knowledge of the condition presumably being evaluated. For example, when recall of the second and third trial of a word list are worse than the first, or when scores are by far better for rare items than com- monplace ones in a confrontation naming test, the examiner’s suspicions of poor motivation should be aroused. However, most patients want to preserve their dignity and perform at their best, even when monetary re- wards for impairment are anticipated. Other interpretation problems may come from the design of the tests themselves (4). Many ques- tionnaires and check lists generate a summed score based on points for positive answers. While this one-dimensional quantitative variable is readily accessible to statistical treatment, it may hide different – and sometimes, very different – answers. Cognitive measures should be related to naturalistic ob- servations in so far as possible. In case of disagreement between test scores and daily observations, believe the last. It also includes a qualitative dimension that takes into account all the factors that make sense of the score, including the patient’s examina- tion behavior and qualitative aspects of the test performances. For exam- ple, assessing cognitive strategies, that is, understanding how a patient performs a task, is often as important as finding out what the patient knows or can do (33). The assessment battery put together for each patient depends upon the evaluation goals, available testing time, and the patient’s strengths and limitations. When many tests are available for a cognitive domain of interest, the examiner should select well-validated tests with norms that fit the patient’s demo- graphic features and that target the examination objectives most closely. Among the test characteristics that qualify a test for use, validity is both the most important and may be the most difficult to appraise. Valid- ity refers to how well a task or test assesses what it is supposed to assess. Content validity may be especially difficult to document for many tests of cognitive functions when they are so complex that they provide informa- tion about several variables with more or less information about any one variable depending upon the subject’s capacities. Given these complexi- ties, a common method for establishing content validity compares tests under development with older, widely used ones, the latter being treated as “the gold standard. With this knowledge clinicians can draw logical and reliable con- clusions from their data enabling them to take appropriate action for the patients (e. Test validity studies comparing tests directly typically employ statistical procedures designed for normal (Gaussian, parametric) score distribu- tions. However, some test scores should be reported on ordinal scales as they do not fit a normal distribution (e. Construct validity for these tests can be ascertained too, but by means of different kinds of sta- tistical treatments (i. However, test selection should focus on the known properties of the test and how they relate to the questions pre- sented by the patient; if they have satisfactory construct validity their spe- cific statistical attributes will rarely be relevant in the individual case. Many patients are reluctant to take “school-like” tests or are anxious about fail- ing or appearing stupid on a mental ability measurement. On the other hand, some personality inventories ask questions with no face validity that some patients find intrusive or embarrassing, al- though they may respond well to an inventory with obvious face validity (e. Reliability refers to the extent to which a test will generate the same score in persons with similar abilities under similar retest conditions re- gardless of who is the examiner. The reliability of a test can not be deter- mined with brain impaired subjects as their disorders make them suscep- tible to daily, even hourly variations in their capacities to perform on a test. Behavioral rating scales may have unnecessarily low reliability when the behavioral descriptions are too brief or too vague for consistent scor- ing by different examiners. Two other important characteristics of a test are its sensitivity (the probability of correctly detecting abnormal functioning in an impaired in- dividual) and its specificity (the probability of identifying a person who is intact with respect the condition under consideration; i. Many tests commonly used for cognitive assessments will have high sensitivity because good perfor- mance depends on many different variables, yet their specificity will be very low. For example, the Trail Making Test (34), which can be failed for many different reasons, is very sensitive to brain impairments – as well as stiff fingers or a frozen shoulder – but a poor performance does not imply any specific disorders. Those tests with high specificity have typically been developed to examine only a single, usually relatively uncommon, deficit and are generally not given unless there is reason to believe that the patient may have that kind of deficit. In contrast to the Trail Making Test, the Token Test (35) with high specificity is rarely failed by any but persons with very specific communication disorders. It is also important for examiners to select the most appropriate norms – or tests with appropriate norms – when evaluating test perfor- mances. Ideally they would have been normed for all three demographic at- tributes but this is still rare. Test selection should also be guided by appreciation that some tests do not examine very low levels of functioning (i. Children’s tests may be applicable for very impaired patients as the beginning items are typically simple, thus doing away with floor effects; these test perfor- mance can be interpreted in terms of chronological age (e. Poorly educated patients run the risk of appearing more impaired than they are on academically-based tests such as those involving word usage or arith- metic. Their cognitive potential will often be better estimated by visual reasoning and construction (e. Test selection must take into account the patient’s visual or audito- ry deficits and examiners must be alert to whether a patient needs glasses or hearing aids as, not infrequently, brain impaired patients will not think to bring these important devices to the examination. Test se- lection for aphasic patients is complicated by the fact that many have difficulty processing verbal instructions. For these patients, some func- tions will be untestable, others may be examined by tests from one of several batteries for nonverbal testing (e. While standardization is always desirable, common sense may have to play a greater role in determining how to test pa- tients with sensory and/or motor impairments. Computerized tests may be reasonably well-standardized but be unsuitable for testing those re- habilitation patients who have difficulty with instructions, who require continual monitoring which would interfere with the standardization requirements, and still others who may not be able to stay on track as long as required, whether due to wavering attention, distractibility, poor memory, or fatigue. Test selection will also differ depending upon how much information is needed about the patient. A baseline study on entry into a rehabilitation program may include a wide range of tests examining every major cogni- tive domain. Pre and post testing for an attention retraining program will probably focus almost exclusively on those aspects of attention being trained. Given its specific strengths and weaknesses, each test will be more or less appropriate to one assessment situation or another. A busy clinical practice often requires rapid detection of the presence or absence of symptoms of cognitive impairment and an estimate of their severity. These clinical assessments must be sensitive, brief, sufficiently flexible to accommodate the patient’s capacity to participate, fatigue, or alertness. These brief screening tests may also be used in epidemiological surveys for detecting early mild impairment in the population-at-large to identify those persons needing a more complete evaluation. In contrast, rehabilitation planning requires an extensive inventory of the patient’s cognitive strengths and weaknesses typically using many dif- ferent tests and questionnaires with good ecological validity, as possible.

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Look for the date accompanied by such words as updated best viagra plus 400mg erectile dysfunction devices, modifed purchase viagra plus 400mg online erectile dysfunction nursing interventions, revised, reviewed: ⚬ At the top, bottom, or sidebar of the frst screen or the bottom of the last screen of the site ⚬ In the source code for the database/retrieval system if it is displayed by the Web browser Box 56. Various words are used to show that the content of a database/retrieval system has been changed. Database/retrieval system on the Internet with update/revision date 1674 Citing Medicine Date of Citation for Databases/Retrieval Systems on the Internet (required) General Rules for Date of Citation • Always include the date the database/retrieval system was seen on the Internet • Include the year month and day in that order, such as 2006 May 5 • Use English names for months and abbreviate them using the frst three letters, such as Jan • If a date of update/revision is given, place the date of citation afer it and follow both dates with a right square bracket • If no date of update/revision is given, place citation date information in square brackets • End date information with a period placed outside the closing bracket Specific Rules for Date of Citation • Both a date of update/revision and a date of citation Box 59. Various words are used to show that the content of a database/retrieval system has been changed. For example: reviewed 2004 Sep 1; modifed 2006 Aug 17; ⚬ Separate words by a semicolon and a space ⚬ End the date(s) of update/revision with a semicolon and a space • Enter the date cited in the format year month day • Place all dates of update/revision and the date of citation in one set of square brackets • End with a period placed outside the closing bracket Examples: Health Library for Disasters [Internet]. Databases/Retrieval Systems on the Internet 1675 Box 59 continued from previous page. Database of Human Disease Causing Gene Homologues in Dictyostelium Discoideum [Internet]. Database/retrieval system on the Internet published with equal text in two languages Notes for Databases/Retrieval Systems on the Internet (optional) General Rules for Notes • Notes is a collective term for any useful information given afer the citation itself • Complete sentences are not required • Be brief Specific Rules for Notes • System requirements • Other types of material to include in notes Box 64. System requirements describe the sofware and hardware needed to view the database/ retrieval system. Databases/Retrieval Systems on the Internet 1679 Box 64 continued from previous page. Environmental Enrichment for Primates: Annotated Database on Environmental Enrichment and Refnement of Husbandry for Nonhuman Primates [Internet]. Database/retrieval system on the Internet with supplemental note included Databases/Retrieval Systems on the Internet 1681 Examples of Citations to Entire Databases/Retrieval Systems on the Internet 1. Standard citation to an open serial database on the Internet Dryad Digital Repository [Internet]. Database/retrieval system on the Internet with an individual(s) as author Blaxter M. Database/retrieval system on the Internet with optional full names for author Jablonski, Stanley. Database/retrieval system on the Internet with an organization as author American Diabetes Association. National Library of Medicine, Division of Specialized Information 1684 Citing Medicine Services. Database/retrieval system on the Internet with editors where there is no author ® ® Hamosh A, editor. Database/retrieval system on the Internet with no authors or editors Rat Atlas [Internet]. Database/retrieval system on the Internet title with upper/lowercase letters and symbols bioProtocol: a Bio Online Site [Internet]. Berlin: Humboldt-Universitat zu Berlin, Zentrum fur transdisziplinare Geschlechterstudien. Database/retrieval system on the Internet with title ending in other than a period Is Your Doctor Certifed? Database/retrieval system on the Internet in a language other than English Sistema Informativo Sanitario [Internet]. Rome: Ministero della Salute, Direzione General del Sistema Informativo e Statistico. Berlin: Humboldt-Universitat zu Berlin, Zentrum fur transdisziplinare Geschlechterstudien. Rome: Ministero della Salute, Direzione General del Sistema Informativo e Statistico. Database/retrieval system on the Internet published with equal text in two languages Cardiovascular Disease Surveillance On-line = Surveillance des Maladies Cardio- vasculaires en Direct [Internet]. Database/retrieval system on the Internet with an edition or version Dietary Supplement Label Database [Internet]. Databases/Retrieval Systems on the Internet 1687 WormBase: the Biology and Genome of C. Copenhagen: International Health Terminology Standards Development Organization; 2011 Jan 31 [cited 2011 Jul 14]. Database/retrieval system on the Internet with well known place of publication Current Controlled Trials [Internet]. Database/retrieval system on the Internet with geographic qualifier added to place of publication for clarity Te Cochrane Library [Internet]. Database/retrieval system on the Internet with place of publication inferred WormBase: the Biology and Genome of C. Database/retrieval system on the Internet with unknown place of publication Pfam [Internet]. Database/retrieval system on the Internet with publisher having subsidiary division Nutrition Education for Diverse Audiences [Internet]. Geneva: World Health Organization, Department of Communicable Disease Surveillance and Response, Anti- infective Drug Resistance and Containment Team. National Library of Medicine, Lister Hill National Center for Biomedical Communications. Database/retrieval system on the Internet with joint publication WormBase: the Biology and Genome of C. Database/retrieval system on the Internet with standard date of publication Database of Human Disease Causing Gene Homologues in Dictyostelium Discoideum [Internet]. Geneva: World Health Organization, Department of Communicable Disease Surveillance and Response, Anti- infective Drug Resistance and Containment Team. Te Alberta Atlas of Human Pathology: a Resource for Teachers and Learners in the Health Sciences [Internet]. Environmental Enrichment for Primates: Annotated Database on Environmental Enrichment and Refnement of Husbandry for Nonhuman Primates [Internet]. Database/retrieval system on the Internet with date of copyright instead of date of publication Biozon [Internet]. ProQolid: Patient-Reported Outcome and Quality of Life Instruments Database [Internet]. Database/retrieval system on the Internet with date obtained from earliest material in it PubMed [Internet]. Database/retrieval system on the Internet with unknown date Te Internet Acronym Server [Internet]. Database/retrieval system on the Internet with update/revision date Health Library for Disasters [Internet]. Database of Human Disease Causing Gene Homologues in Dictyostelium Discoideum [Internet]. Database/retrieval system on the Internet with supplemental note included Is Your Doctor Certifed?