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Answers The following are the answers to questions to be found in the Clinical Scenarios at the ends of the chapters indicated cheap bupropion 150 mg with amex. Babinski’s sign normal flexor responses are replaced by extensor responses generic bupropion 150mg fast delivery, big toe turns upwards; in adults this indicates upper motor neurone (pyramidal tract) pathology generic bupropion 150 mg amex. Sengstarken tube) places direct pressure on bleeding points; thus internal bleeding is stopped in the same way that nurses use digital pressure to stop bleeding after arterial lines are removed generic 150mg bupropion mastercard. Calorie (Cal, C) amount of heat needed to raise one kilogram of water 1°C at atmospheric pressure (=large calorie, kilocalorie). Circadian rhythm affects various endogenous hormone levels, so that a disturbed Glossary 470 circadian rhythm results in various abnormal body responses (e. Fluids with high colloid osmotic pressures therefore assist return of extravascular fluid (oedema) into the bloodstream. FiO 2 fraction of inspired oxygen (expressed as a decimal fraction, so that FiO2 1. Frank-Starling law the force exerted during each heartbeat is directly proportional to the length or degree of myocardial fibre stretch; thus increasing fibre length (e. General Adaptive Syndrome a reaction to stressors that causes generalised physiological responses throughout the body; first described by Hans Selye (see Chapter 46). Glossary 471 hysteresis literally, the difference between two phenomena; in a medical context, it usually refers to lung differences between inspiration and expiration (pressure/volume curve), where passive elastic recoil allows greater volume in relation to airway pressure during expiration than during inspiration; thus manipulating I:E ratio also manipulates mean airway pressure. Krebs’ cycle (citric acid cycle) a chain of intracellular chemical reactions to metabolise fat for energy. Krebs’ cycle is efficient at energy (adenosine triphosphate) production, but produces metabolic wastes (acids, ketones, carbon dioxide, water); see Chapter 9. At rest, people (and animals) take sigh breaths, which ventilate the lung bases, so helping to prevent atelectasis and infection; like most breaths, this usually occurs spontaneously and unconsciously. The benefits of physiological sigh breaths encouraged manufacturers to incorporate them into artificial ventilators, but sigh breaths during artificial ventilation do not appear to provide any benefits (see Chapter 4). Where artificial technologies replicate capillary function, such as the ‘artificial kidneys’ used for haemofiltration, excessive pressure may rupture the necessarily delicate membrane. As the surface area of the filter becomes progressively engorged with clots, filtrate is forced through a smaller area, increasing transmembrane pressure. Therefore measuring the transmembrane pressure should identify impending rupture of the artificial kidney. Stopping filters before maximum transmembrane pressure is reached enables blood in the circuit to be safely returned to Glossary 473 the patient. V/Q ratio (alveolar) ventilation to (pulmonary capillary) perfusion ratio; normal V/Q=0. Desautels (eds) Mechanical Ventilation , Edinburgh: Churchill Livingstone: 307–26. Price (eds) Managing the Nursing Priorities in Intensive Care , Dinton: Quay Books: 134–70. Withington (eds) Textbook of Intensive Care London: Chapman & Hall: 577–83 Asensio, J. Pesce (eds) Clinical Chemistry: Theory, Analysis, Correction St Louis: Mosby: 213–49. References 478 ——(1996) ‘Toward a theory regarding the pathogenesis of the septic inflammatory response syndrome: what we do know and do not know about cytokine regulation’, Critical Care Medicine 24(1): 163–72. Boyer (eds) Hepatology: A Textbook of Liver Disease , 3rd edn, Philadelphia: W B Saunders: 720–63. British Paediatric Association (1993) The Care of Critically Ill Children: Report of a Multidisciplinary Working Party London: British Paediatric Association. Wilson (eds) Pathophysiology: Clinical Concepts of Disease Processes , St Louis: Mosby: 421–46. Cochrane Injuries Group Albumin Reviewers (1998) ‘Human albumin in critically ill patients: systemic review of randomised control trials’, British Medical Journal 317(7153): 235–40.

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Bitemark analysis has not been exempt from the challenges accompanying the advances in scien- tifc techniques and the learning curves associated with them order 150mg bupropion with amex. In the major- ity of the bitemark cases reported over the last ffy plus years in the United States order bupropion 150 mg with visa, this evidence has been used primarily to link a suspected biter to a specifc victim buy 150mg bupropion with amex. Bitemark evidence purchase 150 mg bupropion overnight delivery, however, has other advantages that are useful to the criminal justice system apart from the specifcs of linking a specifc individual to the crime or victim. A bitemark, on the other hand, is not accidentally or casually inficted and is an indication of intimate and violent interaction. If bitemark analysis can lead to the inclusion or exclusion of suspects, that is very powerful evidence indeed. For a bitemark to be useful for analysis it must contain abundant information and the teeth that made the mark must be very distinctive. Because of the high number of variables involved in bitemark evidence, the specifcity of associating a bitemark to a single suspect is low. For bitemarks these useful areas most ofen involve showing evidence of vio- lence. Bitemarks indicate violence, pain, a struggle, with the possibility of both ofensive and defensive bites. Additionally and importantly, bitemarks in skin may produce a profle of the biter. If the individual and specifc char- acteristics of the teeth are recorded in skin, forensic odontologists may be Bitemarks 361 able to determine tooth position, spacing between teeth, broken or missing teeth, and other individualizing features (Figures 14. With bites in other substrates, be they foodstufs such as cheese, cookies, bologna, or chewing gum, or nonfood items, like expanded polystyrene cups, pencils, or golf tees, with almost any item that can go into the mouth, forensic dentists may be able to isolate specifc individual tooth characteristics that are found in the teeth of the suspected biter. Although bites in material other than skin do not indicate violence, they may have the ability to show greater detail of both class and specifc individual dental characteristics. Te characterization of bites in human skin in relation to the time of death of victims is another area in which bitemark evidence may prove to be valuable. As in the 1975 Marx case with the bitemark on the nose, or in other cases where the three-dimensional nature of the marks, especially the retention of indentations from the teeth, played a prominent role, a forensic odontologist may be able to ofer an opinion related to when the wound was inficted in relation to the time of death. Forensic odontologists must be very careful to not overstate the signifcance or accuracy of this fnding, and limit the opinion, if and when indicated, to “around the time of death. Advances in science when applied to bitemark analysis and interpreta- tion are very likely to provide greater assistance to the examining and testify- ing expert and to enhance the value of evidence in specifc cases. It is the responsibility of attorneys to ask the appropriate questions to get the whole truth from expert witnesses. Experts for the prosecution in a criminal bitemark case may be pressured to provide a “positive link” between the putative biter and the bitemark. With the best evidence and a limited or closed population odontologists may be able to associate the two with rea- sonable medical or dental certainty, but never with absolute certainty. Y,” “only one person in X million or billion could make such a mark,” or “indeed and without doubt”) are inappropriate and scientifcally unsupportable. Te meanings of reasonable scientifc, medical, or dental certainty are consistent with the legal phrase “beyond reasonable doubt. Determinations with reasonable dental/medical/scientifc certainty, like determinations beyond reasonable doubt, should be logically derived from the evidence or absence of evidence. As we have seen from the tragic errors of the past, a misidentifcation of a bitemark can lead to the incarceration of an innocent person and, consequently, freedom for the guilty person, who can continue to kill. Te consequences to the expert who misidentifes a bite- mark or gives improper testimony can be terrible, legally, fnancially, emo- tionally, personally, and publicly. Te expert may be subject to legal action brought by the person wrongly accused/convicted. Accounts may be written in newspapers, weblogs, magazines, and books, generating public hostility. All this is in addition to how the expert must feel knowing he was even partly responsible for the incarceration of an innocent man. Te defense expert has just as much responsibil- ity to be truthful and objective as the expert for the prosecution, but errors by defense experts do not carry the same legal, fnancial, or public burden as the errors by a prosecution expert. Defense expert errors may contribute to a guilty suspect being freed, but the defense expert will rarely be publicly humiliated or sued.

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Factor 2 generic bupropion 150 mg fast delivery, physical and fixed safe 150 mg bupropion, had 14 risks of their efforts to their self-structure (Das discount bupropion 150 mg, items with factor loadings from bupropion 150mg otc. Factor 3, alert process requires knowledge of the adaptation en- processing, had nine items with loadings from. Lecky (1961) proposed the Theory ing awareness involves retrieving information from of Self-consistency to conceptualize a person as a one’s mind and recognizing what has worked for holistic and consistent structure. It can be viewed as a self- Self-consistency Theory is that people are moti- regulating process (Carver & Scheier, 1991). The vated to act in a way that is congruent with their overall function of such cognitive processing is to sense of self and thereby maintain intactness when minimize discrepancies between a desirable sense facing potentially challenging situations. It includes tain self-consistency in the transaction between the cognitive input processing of receiving, analyzing, person and the environment (Elliot, 1986, 1988; storing, memory, successive processing, and Lecky, 1961; Rogers, 1961; Roy & Roberts, 1981), arousal-attention (Roy, 1988b, 2001). Example one initiates cognitive and emotional responses items were “gather information,”“recall past strate- (Roy & Andrews, 1991). Examples of items in- clude “try to maintain balance,” “change physical activity,” “picture actions,” and “share concerns to maintain health. Klarkowska, 1987; Ahan and Zhan, 1994) report Some examples of items were “useful to focus,” that older persons with greater self-consistency had “tend not to blame self,”“get away by self,” and “put more positive levels of well-being. Internal con- changes in aging than did those who had less con- sistency reliability of these five subscales ranged sistency of self-perceptions. Their find- individual has two subareas: the physical self and ings suggested that the older people who had a the personal self. The physical self includes two stability of self-concept coped well in stressful en- components: body sensation and body image; and counters. Therefore, the critical task for older the personal self has three components: selfconsis- tency, self-ideal, and moral-ethical-spiritual self. The critical task for older people is to Conceptual Development maintain self-consistency by transcending internal and external losses in the aging Self-consistency was introduced during the devel- process. These authors noted that people strive to maintain a consistent people is to maintain self-consistency by transcend- self-organization and thus avoid disequilibrium ing internal and external losses in the aging process. An example of a reverse-scored item Roy & Andrews, 1991; Wylie, 1989), Zhan devel- was: “I feel mixed up about what I am really like. Therefore, self-perception and self- a score range from 51 to 104, a mean total score of evaluation are consciously available and can be 85. High social within human development are the physical anxiety leads to less self-consistency (Elliot, 1986). Roy’s basic theoretical premises are that individuals are rarely passive in the face of Problem and Significance what happens to them. They are adaptive, self- Hearing loss is one of the most common conditions protective, and functional in the face of setbacks, affecting older adults. One in three people older and seek higher levels of adaptation by enhancing than 60 and a half of those older than 85 have hear- person and environment interactions. People seek ing loss (National Institute on Deafness and Other to change things if they can, and when they cannot, Communication Disorders, 2001). The degree and they may use cognitive adaptation processes to types of hearing loss in older persons vary, ranging change the meaning of the situation in order to from decreased sensitivity to high frequency tones, protect themselves and enhance their selves and to peripheral loss, sensorineural loss, presbycusis, their world (Lazarus, 1991; Roy & Andrews, 1999; or tinnitus (Maguire, 1985; Ritter, 1991). To empirically validate Roy’s generic sons with presbycusis, for example, have more dif- theoretical proposition relating the cognator ficulty filtering out background noises (Von Wedel, processes to adaptation, the author conducted a Von Wedel, & Streppel, 1990). Tinnitus, a common quantitative study to examine the relationship be- hearing problem, is characterized by the symptoms tween cognitive adaptation processes and the main- of ringing, buzzing, hissing, whistling, or swishing tenance of self-consistency in older persons with sounds arising in the ear, and it affects nearly 11 impaired hearing. Hearing serves as a sensory input necessary for Based on Roy’s Adaptation Model—specifically, on one’s interaction with the changing environment the cognator subsystem of the individual—hearing and for a number of critical adaptive functions. The sense of hearing initiates cognitive coping efforts to bring about augments visual cues for orienting individuals in the effective adaptation: the maintenance of self- space and for locating other people and objects. Personal characteristics and social, Loss of hearing can have profound psychological cultural, and environmental factors influence effects on one’s life, including feeling insecure, re- maintenance of self-consistency through coping jected, and depressed; family stress; social isolation; and adaptation processes.

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